Effects of high-intensity exercise and protein supplement on muscle mass in ADL dependent older people with and without malnutrition: a randomized controlled trial

Current Research on Vitamin D Supplementation against Sarcopenia: A Review of Clinical Trials

Vitamin D plays an important role in skeletal muscle function and metabolism. The aim of this review was A) to discuss the clinical evidence of vitamin D supplementation either alone or combined with other strategies in the prevention of sarcopenia in non-sarcopenic individuals and B) to critically discuss the clinical evidence on the effect of vitamin D combined with other strategies on muscle strength, mass and function in sarcopenic individuals without vitamin D deficiency. Sparse clinical data on non-sarcopenic individuals indicate that vitamin D alone has a subtle beneficial effect on knee extensor strength at doses 880-1600 IU/day without improving handgrip strength or muscle mass. When co-administered with other supplements such as protein, mixed effects appear to prevent the decline of muscle mass, possibly delaying the onset of sarcopenia in non-sarcopenic individuals, at doses of 800-1,000 IU/day over 6-12 weeks. In sarcopenic individuals, vitamin D 100-1,000 IU/day co-supplementation with protein results in increased handgrip strength between 9.8-40.5%. However, there is no strong clinical evidence that vitamin D dosage correlates with changes in muscle strength or mass. Potential sources of discrepancy among studies are discussed. Future studies with appropriate experimental design are essential to dissect the net effect of vitamin D on sarcopenia.

Diagnostic Criteria and Prognostic Relevance of Sarcopenia in Patients with Inflammatory Bowel Disease-A Systematic Review

BACKGROUND

Sarcopenia is a syndrome characteristic in elderly patients and is also associated with a significant proportion of chronic disorders such as inflammatory bowel disease (IBD). In this case, it can lead to a worse prognosis of the disease and a decreased quality of life.

STUDY AIM

This study aims to identify the best ways to diagnose sarcopenia in patients with IBD, establish its impact on the course of the disease, and find preventive methods to counteract the effects of sarcopenia in the outcome of patients with IBD and, therefore, minimize disabilities and increase the health-related quality of life (HRQoL).

MATERIAL AND METHODS

A systematic review with the Prospero registration number CRD42023398886 was performed in PubMed and Web of Science databases, evaluating all original articles published in the last 10 years (clinical trials and randomized control trials) that describe sarcopenia and IBD in the human adult population.

RESULTS

From the 16 articles that were included, 5 articles defined sarcopenia by the skeletal muscle index (SMI) and reported data regarding its correlation with body composition: BMI; visceral fat (VF); subcutaneous fat (SC); and VF/SC index. Other articles evaluated the link between sarcopenia and the total psoas muscle area, thigh circumference, calf circumference, subjective global assessment, hand grip strength, and appendicular SMI, alongside inflammatory markers such as IL-6 and C-reactive protein, level of disability, malnutrition, frailty, resistance training alone and in combination with whey protein, and infliximab treatment.

DISCUSSIONS AND CONCLUSIONS

There is a great heterogeneity regarding the assessment criteria and methods used to diagnose sarcopenia due to the variability of population characteristics, both anthropometric and socio-cultural, alongside the high variability in the cut-offs. Therefore, any method which identifies sarcopenia in IBD patients, thus enabling intervention, may provide good results for patient quality of life and outcomes.

A Review of Rehabilitation Benefits of Exercise Training Combined with Nutrition Supplement for Improving Protein Synthesis and Skeletal Muscle Strength in Patients with Cerebral Stroke

Cerebral vascular accident (CVA) is one of the main causes of chronic disability, and it affects the function of daily life, so it is increasingly important to actively rehabilitate patients' physical functions. The research confirmed that the nutrition supplement strategy is helpful to improve the effect of sports rehabilitation adaptation and sports performance. The patients with chronic strokes (whose strokes occur for more than 6 months) have special nutritional needs while actively carrying out rehabilitation exercises, but there are still few studies to discuss at present. Therefore, this paper will take exercise rehabilitation to promote muscle strength and improve muscle protein synthesis as the main axis and, through integrating existing scientific evidence, discuss the special needs of chronic stroke patients in rehabilitation exercise intervention and nutrition supplement one by one. At the same time, we further evaluated the physiological mechanism of nutrition intervention to promote training adaptation and compared the effects of various nutrition supplement strategies on stroke rehabilitation. Literature review pointed out that immediately supplementing protein nutrition (such as whey protein or soybean protein) after resistance exercise or endurance exercise can promote the efficiency of muscle protein synthesis and produce additive benefits, thereby improving the quality of muscle tissue. Recent animal research results show that probiotics can prevent the risk factors of neural function degradation and promote the benefits of sports rehabilitation. At the same time, natural polyphenols (such as catechin or resveratrol) or vitamins can also reduce the oxidative stress injury caused by animal stroke and promote the proliferation of neural tissue. In view of the fact that animal research results still make up the majority of issues related to the role of nutrition supplements in promoting nerve repair and protection, and the true benefits still need to be confirmed by subsequent human studies. This paper suggests that the future research direction should be the supplement of natural antioxidants, probiotics, compound nutritional supplements, and integrated human clinical research.

Effects of nutritional supplement and resistance training for sarcopenia in patients with inflammatory bowel disease: A randomized controlled trial

BACKGROUND

Nutritional supplementation and resistance training are broadly recommended as part of the treatment of sarcopenia, but studies that have evaluated interventions in inflammatory bowel disease patients with sarcopenia are lacking. The aim of this study was to evaluate the effects of nutritional supplementation and resistance training for improving height-adjusted appendicular skeletal muscle mass (ASM/H2) and medical indices in patients with inflammatory bowel disease.

METHODS

This randomized, double-blind, placebo-controlled trial of forty-five participants was performed at Huadong Hospital Affiliated to Fudan University in Shanghai from September 2020 to June 2021. Eligible participants were randomly assigned to receive whey protein (10 g/d) or placebo (10 g/d) for 8 weeks while completing a resistance training program (3 times a week). Data such as ASM/H2 and other medical indices were collected at baseline and at 4 and 8 weeks of intervention.

RESULTS

Fifteen participants were allocated to the resistance training and whey protein (RT+WP) group, and thirteen participants were allocated to the resistance training and placebo (RT+placebo) group. The ASM/H2 significantly increased in the RT+WP group after 4 and 8 weeks of intervention, and the ASM/H2 of the RT+WP group was significantly higher than that of the RT+placebo group after 4 and 8 weeks of intervention (F = 1.092, P = .035). Both interventions significantly increased albumin (F = 7.214, P = .003). Hemoglobin and creatinine significantly increased in the RT+WP group (F = 3.592, P = .035; F = 3.922, P = .033, respectively). In addition, a significant group × time interaction was not observed for body mass index, 5-time chair stand test time, 3-metre walk speed, grip strength, waist circumference, hip circumference, or waist-to-hip ratio (P > .05).

CONCLUSIONS

Nutritional supplementation may be effective in improving sarcopenia, as well as many other physiological indicators during resistance training.

Impact of physical activity programs and services for older adults: a rapid review

Background

Knowledge of which physical activity programs are most effective for older adults in different sub-populations and contexts is limited. The objectives of this rapid review were to: 1) Overview evidence evaluating physical activity programs/services for older adults; and 2) Describe impact on physical activity, falls, intrinsic capacity (physical domain), functional ability (physical, social, and cognitive/emotional domains), and quality of life.

Methods

We conducted a rapid review of primary studies from 350 systematic reviews identified in a previous scoping review (March 2021: PEDro, MEDLINE, CINAHL, Cochrane Database). For Objective 1, we included intervention studies investigating physical activity programs/services in adults ≥ 60 years. Of these, we included good quality (≥ 6/10 PEDro scale) randomised controlled trials (RCTs) with ≥ 50 participants per group in Objective 2.

Results

Objective 1: Of the 1421 intervention studies identified from 8267 records, 79% were RCTs, 87% were in high income countries and 39% were good quality. Objective 2: We identified 87 large, good quality RCTs (26,861 participants). Overall activity promotion, structured exercise and recreation/sport had positive impacts (≥ 50% between-group comparisons positive) across all outcome domains. For overall activity promotion (21 intervention groups), greatest impacts were on physical activity (100% positive) and social outcomes (83% positive). Structured exercise (61 intervention groups) had particularly strong impacts on falls (91% positive), intrinsic capacity (67% positive) and physical functioning (77% positive). Recreation/sport (24 intervention groups) had particularly strong impacts on cognitive/emotional functioning (88% positive). Multicomponent exercise (39 intervention groups) had strong impacts across all outcomes, particularly physical activity (95% positive), falls (90% positive) and physical functioning (81% positive). Results for different populations and settings are presented.

Conclusion

Evidence supporting physical activity for older adults is positive. We outline which activity types are most effective in different populations and settings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12966-022-01318-9.

Protein interventions augment the effect of resistance exercise on appendicular lean mass and handgrip strength in older adults: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Increased protein intake is suggested as a strategy to slow or reverse the loss of muscle mass and strength observed in sarcopenia, but results from studies that directly tested this possibility have been inconsistent.

OBJECTIVES

We assessed the evidence on the effects of whole protein supplementation or higher-protein diets, without the use of amino acids or supplements known to stimulate hypertrophy, alone or in combination with resistance exercise (RE) interventions, on lean body mass (LBM) and strength in older adults.

METHODS

A systematic search was conducted using PubMed, Medline, Web of Science, and Cochrane CENTRAL databases from January 1990 to July 2021. Randomized controlled trials that assessed the effects of protein supplementation and/or higher-protein dietary interventions in older adults (mean age ≥50 y) on total LBM, appendicular lean mass (ALM), and handgrip (HG) and knee extension (KE) strength were included.

RESULTS

Twenty-eight studies were identified. In pooled analysis, compared with lower protein controls, protein supplementation did not have a significant positive effect on total LBM [weighted mean difference in change (WMD): 0.34; 95% CI: -0.21, 0.89; I2 = 90.01%], ALM (WMD: 0.4; 95% CI: -0.01, 0.81; I2 = 90.38%), HG strength (WMD: 0.69; 95% CI: -0.69, 2.06; I2 = 94.52%), or KE strength (WMD: 1.88; 95% CI: -0.6, 4.35; I2 = 95.35%). However, in interventions that used also RE, statistically significant positive effects of protein were observed for ALM (WMD: 0.54; 95% CI: 0.03, 1.05; I2 = 89.76%) and HG (WMD: 1.71; 95% CI: 0.12, 3.30; I2 = 88.71%). Meta-regression revealed no significant association between age, per-meal protein dose, duration, and baseline protein intake with change in any outcome. Subgroup analysis revealed the statistically significant effects on ALM occurred only in sarcopenic/frail populations (WMD: 0.88; 95% CI: 0.51, 1.25; I2 = 79.0%). Most studies (n = 22) had some risk of bias.

CONCLUSIONS

In older adults performing RE, increased protein intake leads to greater ALM and HG strength compared with lower protein controls. Without RE, protein has no additional benefit on changes in total LBM, ALM, or HG strength.

What long-term care interventions have been published between 2010 and 2020? Results of a WHO scoping review identifying long-term care interventions for older people around the world

OBJECTIVE

The global population is rapidly ageing. To tackle the increasing prevalence of older adults' chronic conditions, loss of intrinsic capacity and functional ability, long-term care interventions are required. The study aim was to identify long-term care interventions reported in scientific literature from 2010 to 2020 and categorise them in relation to WHO's public health framework of healthy ageing.

DESIGN

Scoping review conducted on PubMed, CINHAL, Cochrane and Google Advanced targeting studies reporting on long-term care interventions for older and frail adults. An internal validated Excel matrix was used for charting.Setting nursing homes, assisted care homes, long-term care facilities, home, residential houses for the elderly and at the community.

INCLUSION CRITERIA

Studies published in peer-reviewed journals between 1 January 2010 to 1 February 2020 on implemented interventions with outcome measures provided in the settings mentioned above for subjects older than 60 years old in English, Spanish, German, Portuguese or French.

RESULTS

305 studies were included. Fifty clustered interventions were identified and organised into four WHO Healthy Ageing domains and 20 subdomains. All interventions delved from high-income settings; no interventions from low-resource settings were identified. The most frequently reported interventions were multimodal exercise (n=68 reports, person-centred assessment and care plan development (n=22), case management for continuum care (n=16), multicomponent interventions (n=15), psychoeducational interventions for caregivers (n=13) and interventions mitigating cognitive decline (n=13).

CONCLUSION

The identified interventions are diverse overarching multiple settings and areas seeking to prevent, treat and improve loss of functional ability and intrinsic capacity. Interventions from low-resource settings were not identified.

Overcoming protein-energy malnutrition in older adults in the residential care setting: A narrative review of causes and interventions

Malnutrition, in particular protein-energy malnutrition, is a highly prevalent condition in older adults, and is associated with low muscle mass and function, and increased prevalence of physical frailty. Malnutrition is often exacerbated in the residential care setting due to factors including lack of dentition and appetite, and increased prevalence of dementia and dysphagia. This review aims to provide an overview of the available literature in older adults in the residential care setting regarding the following: links between sarcopenia, frailty, and malnutrition (in particular, protein-energy malnutrition (PEM)), recognition and diagnosis of malnutrition, factors contributing to PEM, and the effectiveness of different forms of protein supplementation (in particular, oral nutritional supplementation (ONS) and protein-fortified foods (PFF)) to target PEM. This review found a lack of consensus on effective malnutrition diagnostic tools and lack of universal requirement for malnutrition screening in the residential care setting, making identifying and treating malnutrition in this population a challenge. When assessing the use of protein supplementation in the residential care setting, the two primary forms of supplementation were ONS and PFF. There is evidence that ONS and PFF increase protein and energy intakes in residential care setting, yet compliance with supplementation and their impact on functional status is unclear and conflicting. Further research comparing the use of ONS and PFF is needed to fully determine feasibility and efficacy of protein supplementation in the residential care setting.

High-intensity functional exercise in older adults with dementia: A systematic review and meta-analysis

OBJECTIVE

This study aimed to investigate the efficacy of high-intensity functional exercise among older adults with dementia.

METHODS

In this systematic review and meta-analysis of randomized controlled trials, we collected articles published before August 2020 from PubMed, Embase, and the Cochrane Library to evaluate the effect of high-intensity functional exercise on older adults with dementia. Primary outcomes included improvements in balance function and gait performance (speed, cadence, and stride length). The secondary outcomes included lower limb strength, activities of daily living, psychiatric well-being, depression, and cognition. Furthermore, we performed subgroup analysis with two high-intensity functional exercise programs: the Umeå program and Hauer's program.

RESULTS

We identified 15 articles describing six trials including older adults with dementia undergoing high-intensity functional exercise or control activity. The meta-analysis indicated that high-intensity functional exercise, both in Hauer's program and in the Umeå program, significantly improved balance function (pooled standardized mean difference 0.57, 95% confidence interval 0.31-0.83). Hauer's program significantly improved gait speed, cadence, stride length, and lower limb strength. Beneficial effects on speed, cadence, and lower limb strength were retained for several months. The Umeå program facilitated activities of daily living and psychiatric well-being, with effects on activities of daily living lasting several months. In the only eligible trial, no effects on cognition were observed. Adverse effects of high-intensity functional exercise were minimal to none.

CONCLUSIONS

High-intensity functional exercise is generally safe and is recommended for older individuals with mild or moderate dementia to provide benefits in motor performance and daily functioning.

Milk for Skeletal Muscle Health and Sarcopenia in Older Adults: A Narrative Review

Skeletal muscle aging manifests as a decline in muscle quantity and quality that accelerates with aging, increasing the risk of sarcopenia. Sarcopenia is characterized by a loss of muscle strength and mass, and contributes to adverse health outcomes in older adults. Intervention studies have shown that sarcopenia may be treated by higher protein intake in combination with resistance exercise (RE). In comparison, less is known about the role of whole protein-containing foods in preventing or treating sarcopenia. Liquid milk contains multiple nutrients and bioactive components that may be beneficial for muscle, including proteins for muscle anabolism that, alone or with RE, may have myoprotective properties. However, there is a lack of evidence about the role of milk and its effects on muscle aging. This narrative review considers evidence from three observational and eight intervention studies that used milk or fortified milk, with or without exercise, as an intervention to promote muscle health and function in older adults (aged 50–99 years). The observational studies showed no association between higher habitual milk consumption and muscle-related outcomes. The results of intervention studies using fortified milk in relation to elements of sarcopenia were also negative, with further inconclusive results from the studies using a combination of (fortified) milk and exercise. Although milk contains nutrients that may be myoprotective, current evidence does not show beneficial effects of milk on muscle health in older adults. This could be due to high habitual protein intakes (>1.0 g/kg BW/d) in study participants, differences in the type of milk (low-fat vs whole) and timing of milk consumption, length of interventions, as well as differences in the sarcopenia status of participants in trials. Adequately powered intervention studies of individuals likely to benefit are needed to test the effectiveness of a whole food approach, including milk, for healthy muscle aging.

The prevalence of sarcopenia risk and associated factors in patients aged 65-79 years living in a district of Izmir province of Turkey

Objectives

This study aims to investigate the prevalence of sarcopenia risk and associated factors in a community-dwelling elderly population in a district of Izmir province of Turkey.

Patients and methods

This cross-sectional study used a cluster sampling method to define sarcopenia risk and associated factors in population aged 65-79 years in Balcova district and a total of 254 participants (114 males, 140 females; mean age 70.0 years; range 65 to 79 years) were included between October 2014 and December 2014. The dependent variables were low gait speed (LGS), low grip strength (LGrS), having both LGS and LGrS, sarcopenia risk according to the European Group on Sarcopenia for Older People (EWGSOP) algorithm. The independent variables were socio-demographic and socio-economic variables, health-related behavioral factors, and health status variables. The gait speed was measured on a four-meter length with a stopwatch. The grip strength was measured using a hand-held dynamometer. The logistic regression models were used to identify associated risk factors for sarcopenia.

Results

The prevalence of LGS was found to be 45.0%, LGrS to be 49.8%, having both LGS and LGrS to be 30.1%, and sarcopenia risk according to EWGSOP to be 64.8%. The main associated factors of having any sarcopenia risk were increasing age and having a sedentary lifestyle or being underactive.

Conclusion

Our study results show that sarcopenia risk is high in a community-dwelling elderly population living in Balcova district of Izmir province of Turkey. Physical activity levels of elderly should be increased to decrease this high burden.

Hypoalbuminemia as a marker of protein metabolism disarrangement in patients with stable chronic heart failure

BACKGROUND

Despite therapeutic advances, chronic heart failure (CHF)-related mortality and hospitalization is still unacceptably high. Evidence shows that muscular wasting, sarcopenia, cachexia are independent predictors of mortality and morbidity in CHF and are signs of protein metabolism disarrangement (PMD), which involve all body proteins including circulating one. We postulate that circulating human serum albumin (HSA) could be a marker of PMD and catabolic low-grade inflammation (LGI) in CHF patients.

METHODS

One hundred sixty-six stable CHF patients (73% males), with optimized therapy referred to cardiac rehabilitation, were retrospectively divided into three groups based on their HSA concentration: ≥3.5 g/dL (normal value), 3.2-3.49 g/dL (low value); ≤3.19 g/dL (severe value). Hematochemical analyses (including circulating proteins and inflammatory markers) and body mass composition (by Bioelectrical Impedance Vector Analysis) were collected and compared. Correlations and multivariate regression were performed.

RESULTS

Despite being overweight (BMI=27 kg/m2), 75% of patients had reduced HSA (<3.5 g/dL) with suspectable sarcopenia, and 35% of all patients had remarkably lower albumin concentrations (<3.19 g/dL). Hypoalbuminemic patients were disable, older, with reduced muscular proteins, bilirubin and hemoglobin, increased extracellular water and LGI (P<0.01). HSA correlated with all of these parameters (all: P<0.01). Age, LGI, BMI, free-fat Mass, and bilirubin were independent predictors of HSA concentration. All these findings were male-dependent.

CONCLUSIONS

HSA could be considered a simple marker of PMD and LGI in CHF patients. Evaluation of PMD and gender differences should be considered in new CHF clinical trials.

The Role of Muscle Mass Gain Following Protein Supplementation Plus Exercise Therapy in Older Adults with Sarcopenia and Frailty Risks: A Systematic Review and Meta-Regression Analysis of Randomized Trials

Aging and frailty are associated with a high risk of lean mass (LM) loss, which leads to physical disability and can be effectively alleviated by protein supplementation (PS) and muscle strengthening exercise (MSE). In this study, the associations between LM gain and PS + MSE efficacy (measured using physical outcomes) in elderly patients with a high risk of sarcopenia or frailty were identified. A comprehensive search of online databases was performed to identify randomized controlled trials (RCTs) reporting the efficacy of PS + MSE in elderly patients with sarcopenia or frailty. The included RCTs were analyzed using meta-analysis and risk of bias assessment. We finally included 19 RCTs in this meta-analysis with a median (range/total) Physiotherapy Evidence Database score of 7/10 (5-9/10). The PS + MSE group exhibited significant improvements in the whole-body LM (standard mean difference (SMD) = 0.66; p < 0.00001), appendicular LM (SMD = 0.35; p < 0.00001), leg strength (SMD = 0.65; p < 0.00001), and walking capability (SMD = 0.33; p = 0.0006). Meta-regression analyses showed that changes in appendicular LM were significantly associated with the effect sizes of leg strength (β = 0.08; p = 0.003) and walking capability (β = 0.17; p = 0.04), respectively. Our findings suggest that LM gain after PS + MSE significantly contributes to the efficacy of the intervention in terms of muscle strength and physical mobility in elderly patients with a high risk of sarcopenia or frailty.

Effects of Protein Supplementation Combined with Exercise Intervention on Frailty Indices, Body Composition, and Physical Function in Frail Older Adults

Aging poses a high risk of lean mass loss, which can be effectively improved through resistance exercise training (RET), or multicomponent exercise training (MET) as well as nutrition supplementation, such as protein supplementation (PS). This study investigated the effects of PS plus exercise training on frail older individuals. A comprehensive search of online databases was performed to identify randomized controlled trials (RCTs) that reported the efficacy of PS combined with RET or MET in frail older individuals. The included RCTs were analyzed through a meta-analysis and risk-of-bias assessment. We finally included 22 RCTs in the meta-analysis, with a mean (range/total) Physiotherapy Evidence Database score of 6.7 (4⁻9/10). PS plus exercise training significantly improved the frailty status (odds ratio = 2.77; p = 0.006), lean mass (standard mean difference (SMD) = 0.52; p < 0.00001), leg strength (SMD = 0.37; p < 0.00001), and walking speed (SMD = 0.32; p = 0.002). Subgroup analyses revealed that PS plus MET exert significant effects on frailty indices, whereas PS plus RET further improves lean mass. Our findings suggest that PS plus RET as well as MET is effective in improving frailty status, lean mass, muscle strength, and physical mobility in frail older individuals.

Effects of Resistance Training of Peripheral Muscles Versus Respiratory Muscles in Older Adults With Sarcopenia Who are Institutionalized: A Randomized Controlled Trial

This study compares the effects of two resistance training programs in peripheral and respiratory musculature on muscle mass and strength and physical performance and identifies the appropriate muscle mass parameter for assessing the intervention effects. Thirty-seven institutionalized older Spanish adults with sarcopenia were analyzed: control group (n = 17), respiratory muscle training group (n = 9), and peripheral muscle training group (n = 11). Measured outcomes were appendicular skeletal muscle mass (ASM/height², ASM/weight, and ASM/BMI), isometric knee extension, arm flexion and handgrip strength, maximal inspiratory and expiratory pressures, and gait speed pre- and postintervention. Trained groups participated in a 12-week program and improved in maximum static inspiratory pressure, maximum static expiratory pressure, knee extension, and arm flexion (p < .05), whereas nonsignificant changes were found in gait speed and ASM indexes pre- and postintervention in the three groups. In conclusion, resistance training improved skeletal muscle strength in the studied population, and any ASM index was found to be appropriate for detecting changes after physical interventions.

ESPEN guideline on clinical nutrition and hydration in geriatrics

BACKGROUND

Malnutrition and dehydration are widespread in older people, and obesity is an increasing problem. In clinical practice, it is often unclear which strategies are suitable and effective in counteracting these key health threats.

AIM

To provide evidence-based recommendations for clinical nutrition and hydration in older persons in order to prevent and/or treat malnutrition and dehydration. Further, to address whether weight-reducing interventions are appropriate for overweight or obese older persons.

METHODS

This guideline was developed according to the standard operating procedure for ESPEN guidelines and consensus papers. A systematic literature search for systematic reviews and primary studies was performed based on 33 clinical questions in PICO format. Existing evidence was graded according to the SIGN grading system. Recommendations were developed and agreed in a multistage consensus process.

RESULTS

We provide eighty-two evidence-based recommendations for nutritional care in older persons, covering four main topics: Basic questions and general principles, recommendations for older persons with malnutrition or at risk of malnutrition, recommendations for older patients with specific diseases, and recommendations to prevent, identify and treat dehydration. Overall, we recommend that all older persons shall routinely be screened for malnutrition in order to identify an existing risk early. Oral nutrition can be supported by nursing interventions, education, nutritional counseling, food modification and oral nutritional supplements. Enteral nutrition should be initiated if oral, and parenteral if enteral nutrition is insufficient or impossible and the general prognosis is altogether favorable. Dietary restrictions should generally be avoided, and weight-reducing diets shall only be considered in obese older persons with weight-related health problems and combined with physical exercise. All older persons should be considered to be at risk of low-intake dehydration and encouraged to consume adequate amounts of drinks. Generally, interventions shall be individualized, comprehensive and part of a multimodal and multidisciplinary team approach.

CONCLUSION

A range of effective interventions is available to support adequate nutrition and hydration in older persons in order to maintain or improve nutritional status and improve clinical course and quality of life. These interventions should be implemented in clinical practice and routinely used.

Effect of Protein or Essential Amino Acid Supplementation During Prolonged Resistance Exercise Training in Older Adults on Body Composition, Muscle Strength, and Physical Performance Parameters: A Systematic Review

Objectives:

Loss of muscle mass and strength with aging, sarcopenia, burdens many older adults, making identification of strategies on how to counteract it very relevant—especially to health care providers working in rehabilitation. The aim of this systematic review was to determine the effect of protein or essential amino acid (EAA) supplementation during prolonged resistance exercise training (RT) in older adults. No known stimulants of muscle protein synthesis, or ingredients with an effect on muscle strength/physical function, were allowed with the supplementation, differentiating this systematic review from others.

Data sources and methods:

In January 2017, 4 electronic databases and reference lists were searched for randomized controlled trials investigating the effect of protein or EAA supplementation during RT in older adults (mean age >60 years) on outcomes of body composition, muscle strength, and physical performance. Study selection and data extraction were performed by 2 independent reviewers.

Results

Sixteen studies (1107 participants) fulfilled the eligibility criteria. Methodologic differences between the studies disallowed a meta-analysis. Of the 16 studies, 6 found significant effects on body composition (3 studies), muscle strength (3 studies), and physical performance (2 studies) measures.

Conclusions

The evidence is weak and inconsistent, as benefit of protein or EAA supplementation during RT in older adults is only shown in some studies. The findings indicate that frail/sarcopenic older adults might benefit more than healthy older adults. Further research is needed to allow an interpretation on the importance of study population and design.

Trial registration:

PROSPERO, Reg. no.: CRD42017063808. Registered April 14, 2017.

Protein Supplementation Does Not Significantly Augment the Effects of Resistance Exercise Training in Older Adults: A Systematic Review

Background and aims

Physical activity and nutritional supplementation interventions may be used to ameliorate age-related loss of skeletal muscle mass and function. Previous reviews have demonstrated the beneficial effects of resistance exercise training (RET) combined with protein or essential amino acids (EAA) in younger populations. Whether or not older adults also benefit is unclear. The aim of this review was to determine whether regular dietary supplementation with protein/EAA during a RET regimen augments the effects of RET on skeletal muscle in older adults.

Methods

A literature search was conducted in August 2015 using MEDLINE, EMBASE, SPORTDiscus, and CINAHL Plus to identify all controlled trials using a RET regimen with and without protein/EAA supplementation. Outcome variables included muscle strength, muscle size, functional ability, and body composition.

Results

Fifteen studies fulfilled the eligibility criteria, including 917 participants with a mean age of 77.4 years. Studies involving both healthy participants and those described as frail or sarcopenic were included. Overall, results indicated that protein supplementation did not significantly augment the effects of RET on any of the specified outcomes. Exceptions included some measures of muscle strength (3 studies) and body composition (2 studies). Meta-analyses were conducted but were limited because of methodologic differences between studies, and results were inconclusive.

Conclusions

Systematic review and meta-analysis of controlled trials reveal that protein/EAA supplementation does not significantly augment the effects of progressive RET in older adults.

Systematic review of behaviour change techniques to promote participation in physical activity among people with dementia

PURPOSE

The objective of this study was to systematically review the evidence for the potential promise of behaviour change techniques (BCTs) to increase physical activity among people with dementia (PWD).

METHODS

PsychINFO, MEDLINE, CINAHL, and the Cochrane Central Register of Controlled Trials databases were searched 01/01/2000-01/12/2016. Randomized controlled/quasi-randomized trials were included if they recruited people diagnosed/suspected to have dementia, used at least one BCT in the intervention arm, and had at least one follow-up measure of physical activity/adherence. Studies were appraised using the Cochrane Collaboration Risk of Bias Tool, and BCTs were coded using Michie et al., 2013, Annals of Behavioral Medicine, 46, 81. taxonomy. Intervention findings were narratively synthesized as either 'very promising', 'quite promising', or 'non-promising', and BCTs were judged as having potential promise if they featured in at least twice as many very/quite promising than non-promising interventions (as per Gardner et al., 2016, Health Psychology Review, 10, 89).

RESULTS

Nineteen articles from nine trials reported physical activity findings on behavioural outcomes (two very promising, one quite promising, and two non-promising) or intervention adherence (one quite promising and four non-promising). Thirteen BCTs were used across the interventions. While no BCT had potential promise to increase intervention adherence, three BCTs had potential promise for improving physical activity behaviour outcomes: goal setting (behaviour), social support (unspecified), and using a credible source.

CONCLUSIONS

Three BCTs have potential promise for use in future interventions to increase physical activity among PWD. Statement of contribution What is already known on this subject? While physical activity is a key lifestyle factor to enhance and maintain health and wellbeing amongst the general population, adults rarely participate in sufficient levels to obtain these benefits. Systematic reviews suggest that specific behaviour change techniques can increase physical activity, although one review suggested that self-regulatory techniques may be counterproductive when promoting physical activity among older people. Until now, no systematic review has been conducted to assess which behaviour change techniques may be associated with greater participation in physical activity among people with dementia. What does this study add? Interventions showed mixed promise for increasing physical activity and little effect on participant adherence. Goal setting (behaviour), social support (unspecified), and using a credible source are promising approaches. No technique showed promise for increasing adherence to physical activity interventions among people with dementia.

Nutrition and physical activity in the prevention and treatment of sarcopenia: systematic review

This systematic review summarizes the effect of combined exercise and nutrition intervention on muscle mass and muscle function. A total of 37 RCTs were identified. Results indicate that physical exercise has a positive impact on muscle mass and muscle function in subjects aged 65 years and older. However, any interactive effect of dietary supplementation appears to be limited.

INTRODUCTION

In 2013, Denison et al. conducted a systematic review including 17 randomized controlled trials (RCTs) to explore the effect of combined exercise and nutrition intervention to improve muscle mass, muscle strength, or physical performance in older people. They concluded that further studies were needed to provide evidence upon which public health and clinical recommendations could be based. The purpose of the present work was to update the prior systematic review and include studies published up to October 2015.

METHODS

Using the electronic databases MEDLINE and EMBASE, we identified RCTs which assessed the combined effect of exercise training and nutritional supplementation on muscle strength, muscle mass, or physical performance in subjects aged 60 years and over. Study selection and data extraction were performed by two independent reviewers.

RESULTS

The search strategy identified 21 additional RCTs giving a total of 37 RCTs. Studies were heterogeneous in terms of protocols for physical exercise and dietary supplementation (proteins, essential amino acids, creatine, β-hydroxy-β-methylbuthyrate, vitamin D, multi-nutrients, or other). In 79% of the studies (27/34 RCTs), muscle mass increased with exercise but an additional effect of nutrition was only found in 8 RCTs (23.5%). Muscle strength increased in 82.8% of the studies (29/35 RCTs) following exercise intervention, and dietary supplementation showed additional benefits in only a small number of studies (8/35 RCTS, 22.8%). Finally, the majority of studies showed an increase of physical performance following exercise intervention (26/28 RCTs, 92.8%) but interaction with nutrition supplementation was only found in 14.3% of these studies (4/28 RCTs).

CONCLUSION

Physical exercise has a positive impact on muscle mass and muscle function in healthy subjects aged 60 years and older. The biggest effect of exercise intervention, of any type, has been seen on physical performance (gait speed, chair rising test, balance, SPPB test, etc.). We observed huge variations in regard to the dietary supplementation protocols. Based on the included studies, mainly performed on well-nourished subjects, the interactive effect of dietary supplementation on muscle function appears limited.

The Impact of Dietary Protein or Amino Acid Supplementation on Muscle Mass and Strength in Elderly People: Individual Participant Data and Meta-Analysis of RCT's

OBJECTIVES

Increasing protein or amino acid intake has been promoted as a promising strategy to increase muscle mass and strength in elderly people, however, long-term intervention studies show inconsistent findings. Therefore, we aim to determine the impact of protein or amino acid supplementation compared to placebo on muscle mass and strength in older adults by combining the results from published trials in a meta-analysis and pooled individual participant data analysis.

DESIGN

We searched Medline and Cochrane databases and performed a meta-analysis on eight available trials on the effect of protein or amino acid supplementation on muscle mass and strength in older adults. Furthermore, we pooled individual data of six of these randomized double-blind placebo-controlled trials. The main outcomes were change in lean body mass and change in muscle strength for both the meta-analysis and the pooled analysis.

RESULTS

The meta-analysis of eight studies (n=557) showed no significant positive effects of protein or amino acid supplementation on lean body mass (mean difference: 0.014 kg: 95% CI -0.152; 0.18), leg press strength (mean difference: 2.26 kg: 95% CI -0.56; 5.08), leg extension strength (mean difference: 0.75 kg: 95% CI: -1.96, 3.47) or handgrip strength (mean difference: -0.002 kg: 95% CI -0.182; 0.179). Likewise, the pooled analysis showed no significant difference between protein and placebo treatment on lean body mass (n=412: p=0.78), leg press strength (n=121: p=0.50), leg extension strength (n=121: p=0.16) and handgrip strength (n=318: p=0.37).

CONCLUSIONS

There is currently no evidence to suggest that protein or amino acid supplementation without concomitant nutritional or exercise interventions increases muscle mass or strength in predominantly healthy elderly people.

Effect of Structured Physical Activity and Nutritional Supplementation on Physical Function in Mobility-Limited Older Adults: Results from the VIVE2 Randomized Trial

OBJECTIVES

The interactions between nutritional supplementation and physical activity on changes in physical function among older adults remain unclear. The primary objective of this study was to examine the impact of nutritional supplementation plus structured physical activity on 400M walk capacity in mobility-limited older adults across two sites (Boston, USA and Stockholm, Sweden).

DESIGN

All subjects participated in a physical activity program (3x/week for 24 weeks), involving walking, strength, balance, and flexibility exercises. Subjects were randomized to a daily nutritional supplement (150kcal, 20g whey protein, 800 IU vitamin D) or placebo (30kcal, non-nutritive).

SETTING

Participants were recruited from urban communities at 2 field centers in Boston MA USA and Stockholm SWE.

PARTICIPANTS

Mobility-limited (Short Physical Performance Battery (SPPB) ≤9) and vitamin D insufficient (serum 25(OH) D 9 - 24 ng/ml) older adults were recruited for this study.

MEASUREMENTS

Primary outcome was gait speed assessed by the 400M walk.

RESULTS

149 subjects were randomized into the study (mean age=77.5±5.4; female=46.3%; mean SPPB= 7.9±1.2; mean 25(OH)D=18.7±6.4 ng/ml). Adherence across supplement and placebo groups was similar (86% and 88%, respectively), and was also similar across groups for the physical activity intervention (75% and 72%, respectively). Both groups demonstrated an improvement in gait speed with no significant difference between those who received the nutritional supplement compared to the placebo (0.071 and 0.108 m/s, respectively (p=0.06)). Similar effects in physical function were observed using the SPPB. Serum 25(OH)D increased in supplemented group compared to placebo 7.4 ng/ml versus 1.3 ng/ml respectively.

CONCLUSION

Results suggest improved gait speed following physical activity program with no further improvement with added nutritional supplementation.

Animal-Derived Protein Consumption Is Associated with Muscle Mass and Strength in Community-Dwellers: Results from the Milan EXPO Survey

OBJECTIVES

Behavioral factors, including protein intake, influence the quantity and quality of skeletal muscle. The aim of this study was to explore the relationship between animal-derived protein intake and muscle mass and function in a large sample of unselected community-dwellers.

MATERIAL AND METHODS

The VIP (Very Important Protein) study, conducted during Expo 2015 in Milan, was a population survey aimed at assessing major health metrics in a population outside of the research setting, with a special focus on the relation between animal-derived protein intake and muscle mass and function. A brief questionnaire exploring lifestyle habits, dietary preferences and the consumption of selected foods was administered. Muscle mass was estimated by calf circumference (CC) and mid-arm muscle circumference (MAMC) of the dominant side. Muscle strength of upper and lower extremities was assessed through handgrip strength testing and repeated chair stand test, respectively.

RESULTS

The mean age of the 1,853 participants was 50.3 years (standard deviation: 15.7; range: 18-98 years), of whom 959 (51.7%) were women. Participants in the highest tertile of protein consumption showed better performance at both the handgrip strength (p <0.001) and chair stand tests than those in the lowest tertile (p <0.01). The same results were found for CC (p <0.001) and MAMC (p <0.001). Participants with high protein intake and engaged in regular physical activity showed the higher scores in all the assessed domains.

CONCLUSIONS

The results of the VIP survey suggest an association between animal-derived protein intake and muscle mass and strength across ages. Our findings also indicate a synergistic effect of animal-derived protein intake and physical activity on muscle-related parameters.

Supportive interventions for enhancing dietary intake in malnourished or nutritionally at-risk adults

BACKGROUND

Supportive interventions such as serving meals in a dining room environment or the use of assistants to feed patients are frequently recommended for the management of nutritionally vulnerable groups. Such interventions are included in many policy and guideline documents and have implications for staff time but may incur additional costs, yet there appears to be a lack of evidence for their efficacy.

OBJECTIVES

To assess the effects of supportive interventions for enhancing dietary intake in malnourished or nutritionally at-risk adults.

SEARCH METHODS

We identified publications from comprehensive searches of the Cochrane Library, MEDLINE, Embase, AMED, British Nursing Index, CINAHL, SCOPUS, ISI Web of Science databases, scrutiny of the reference lists of included trials and related systematic reviews and handsearching the abstracts of relevant meetings. The date of the last search for all databases was 31 March 2013. Additional searches of CENTRAL, MEDLINE, ClinicalTrials.gov and WHO ICTRP were undertaken to September 2016. The date of the last search for these databases was 14 September 2016.

SELECTION CRITERIA

Randomised controlled trials of supportive interventions given with the aim of enhancing dietary intake in nutritionally vulnerable adults compared with usual care.

DATA COLLECTION AND ANALYSIS

Three review authors and for the final search, the editor, selected trials from titles and abstracts and independently assessed eligibility of selected trials. Two review authors independently extracted data and assessed risk of bias, as well as evaluating overall quality of the evidence utilising the GRADE instrument, and then agreed as they entered data into the review. The likelihood of clinical heterogeneity amongst trials was judged to be high as trials were in populations with widely different clinical backgrounds, conducted in different healthcare settings and despite some grouping of similar interventions, involved interventions that varied considerably. We were only able, therefore, to conduct meta-analyses for the outcome measures, 'all-cause mortality', 'hospitalisation' and 'nutritional status (weight change)'.

MAIN RESULTS

Forty-one trials (10,681 participants) met the inclusion criteria. Trials were grouped according to similar interventions (changes to organisation of nutritional care (N = 13; 3456 participants), changes to the feeding environment (N = 5; 351 participants), modification of meal profile or pattern (N = 12; 649 participants), additional supplementation of meals (N = 10; 6022 participants) and home meal delivery systems (N = 1; 203 participants). Follow-up ranged from 'duration of hospital stay' to 12 months.The overall quality of evidence was moderate to very low, with the majority of trials judged to be at an unclear risk of bias in several risk of bias domains. The risk ratio (RR) for all-cause mortality was 0.78 (95% confidence interval (CI) 0.66 to 0.92); P = 0.004; 12 trials; 6683 participants; moderate-quality evidence. This translates into 26 (95% CI 9 to 41) fewer cases of death per 1000 participants in favour of supportive interventions. The RR for number of participants with any medical complication ranged from 1.42 in favour of control compared with 0.59 in favour of supportive interventions (very low-quality evidence). Only five trials (4451 participants) investigated health-related quality of life showing no substantial differences between intervention and comparator groups. Information on patient satisfaction was unreliable. The effects of supportive interventions versus comparators on hospitalisation showed a mean difference (MD) of -0.5 days (95% CI -2.6 to 1.6); P = 0.65; 5 trials; 667 participants; very low-quality evidence. Only three of 41 included trials (4108 participants; very low-quality evidence) reported on adverse events, describing intolerance to the supplement (diarrhoea, vomiting; 5/34 participants) and discontinuation of oral nutritional supplements because of refusal or dislike of taste (567/2017 participants). Meta-analysis across 17 trials with adequate data on weight change revealed an overall improvement in weight in favour of supportive interventions versus control: MD 0.6 kg (95% CI 0.21 to 1.02); 2024 participants; moderate-quality evidence. A total of 27 trials investigated nutritional intake with a majority of trials not finding marked differences in energy intake between intervention and comparator groups. Only three trials (1152 participants) reported some data on economic costs but did not use accepted health economic methods (very low-quality evidence).

AUTHORS' CONCLUSIONS

There is evidence of moderate to very low quality to suggest that supportive interventions to improve nutritional care results in minimal weight gain. Most of the evidence for the lower risk of all-cause mortality for supportive interventions comes from hospital-based trials and more research is needed to confirm this effect. There is very low-quality evidence regarding adverse effects; therefore whilst some of these interventions are advocated at a national level clinicians should recognise the lack of clear evidence to support their role. This review highlights the importance of assessing patient-important outcomes in future research.

Exercise Intervention for Anti-Sarcopenia in Community-Dwelling Older People

Sarcopenia is an age-related health problem in general communities. Effective exercise programs against sarcopenia remain necessary for community-dwelling older people. In order to summarize the available knowledge on this subject, we collected English articles from a MEDLINE/Pubmed database examining the effects of exercise interventions on sarcopenia-related outcome measures in community-dwelling older people. When nine articles, including eight randomized controlled trials, were reviewed, most studies demonstrated significant improvements in some outcome measures. Indeed, a significant improvement in the muscle mass in one study, muscle strength in two studies and physical performance in two studies was reported among five studies using exercise (E) alone. A significant improvement in the muscle mass in two studies, muscle strength in one study and physical performance in two studies was also reported among four studies using exercise plus nutritional supplementation (EN). Notably, the EN studies appeared to have less extensive exercise interventions than the E studies. One EN study further exhibited significant improvements in all outcome measures. Collectively, exercise could be used as anti-sarcopenic strategies and nutritional interventions when combined with exercise might play a compensated or perhaps a comprehensive role among community-dwelling older people. Limited studies exist and more studies are required for the optimum programs in the community settings.

Effectiveness of interventions to indirectly support food and drink intake in people with dementia: Eating and Drinking Well IN dementiA (EDWINA) systematic review

Background

Risks and prevalence of malnutrition and dehydration are high in older people but even higher in older people with dementia. In the EDWINA (Eating and Drinking Well IN dementiA) systematic review we aimed to assess effectiveness of interventions aiming to improve, maintain or facilitate food/drink intake indirectly, through food service or dining environment modification, education, exercise or behavioural interventions in people with cognitive impairment or dementia (across all settings, levels of care and support, types and degrees of dementia).

Methods

We comprehensively searched Medline and twelve further databases, plus bibliographies, for intervention studies with ≥3 cognitively impaired adult participants (any type/stage). The review was conducted with service user input in accordance with Cochrane Collaboration’s guidelines. We duplicated assessment of inclusion, data extraction, and validity assessment, tabulating data. Meta-analysis (statistical pooling) was not appropriate so data were tabulated and synthesised narratively.

Results

We included 56 interventions (reported in 51 studies). Studies were small and there were no clearly effective, or clearly ineffective, interventions. Promising interventions included: eating meals with care-givers, family style meals, soothing mealtime music, constantly accessible snacks and longer mealtimes, education and support for formal and informal care-givers, spaced retrieval and Montessori activities, facilitated breakfast clubs, multisensory exercise and multicomponent interventions.

Conclusions

We found no definitive evidence on effectiveness, or lack of effectiveness, of specific interventions but studies were small and short term. A variety of promising indirect interventions need to be tested in large, high-quality RCTs, and may be approaches that people with dementia and their formal or informal care-givers would wish to try.

Trial registration

The systematic review protocol was registered (CRD42014007611) and is published, with the full MEDLINE search strategy, on Prospero (http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42014007611).

Electronic supplementary material

The online version of this article (doi:10.1186/s12877-016-0256-8) contains supplementary material, which is available to authorized users.

Effects of Nutritional Supplements on Muscle Mass and Activities of Daily Living in Elderly Rehabilitation Patients with Decreased Muscle Mass: A Randomized Controlled Trial

OBJECTIVE

To investigate the effects of nutritional intervention with resistance training on skeletal muscle mass in elderly patients with disabilities in a convalescent rehabilitation setting.

DESIGN

A randomized controlled trial. (UMIN Clinical Trials Registry ID: UMIN000006238).

SETTING

A rehabilitation hospital.

PARTICIPANTS

39 elderly patients with decreased skeletal muscle mass in an inpatient convalescence rehabilitation unit.

INTERVENTIONS

A combination of resistance training plus nutritional supplementation (R/N group) or resistance training alone (R group). The training and supplementation were conducted essentially from the patient's admission to discharge (2-6 months).

OUTCOME MEASURES

The patients were evaluated at the time of admission and at the end of the intervention for skeletal muscle mass (calf circumference [CC] as a primary outcome, and arm circumference [AC]), hand grip strength (HG), Mini-Nutritional Assessment-Short Form (MNA®-SF) score, serum albumin level (Alb), body mass index (BMI), and activities of daily living (ADL) as represented by the Barthel Index (BI) score.

RESULTS

Significant treatment effects were seen for CC, AC, BI, Alb in the R/N group compared to the R group. A mean treatment effect of 3.2 (95%CI: 2.0-4.4) was seen in CC, 1.4 (95%CI: 0.8-2.1) was seen in AC, 11.2 (95%CI: 0.5-21.8) was seen in BI, 0.3 (95%CI: 0.1-0.5) was seen in Alb.

CONCLUSION

The results of this study suggest that nutritional intervention added to resistance training during convalescent rehabilitation may improve skeletal muscle mass and activities of daily living.

Effectiveness of interventions to directly support food and drink intake in people with dementia: systematic review and meta-analysis

BACKGROUND

Eating and drinking difficulties are recognised sources of ill health in people with dementia. In the EDWINA (Eating and Drinking Well IN dementiA) systematic review we aimed to assess effectiveness of interventions to directly improve, maintain or facilitate oral food and drink intake, nutrition and hydration status, in people with cognitive impairment or dementia (across all settings, levels of care and support, types and degrees of dementia). Interventions included oral nutrition supplementation, food modification, dysphagia management, eating assistance and supporting the social element of eating and drinking.

METHODS

We comprehensively searched 13 databases for relevant intervention studies. The review was conducted with service user input in accordance with Cochrane Collaboration's guidelines. We duplicated assessment of inclusion, data extraction, and validity assessment, tabulating data, carrying out random effects meta-analysis and narrative synthesis.

RESULTS

Forty-three controlled interventions were included, disappointingly none were judged at low risk of bias. Oral nutritional supplementation studies suggested small positive short term but unclear long term effects on nutritional status. Food modification or dysphagia management studies were smaller and of low quality, providing little evidence of an improved nutritional status. Eating assistance studies provided inconsistent evidence, but studies with a strong social element around eating/drinking, although small and of low quality provided consistent suggestion of improvements in aspects of quality of life. There were few data to address stakeholders' questions.

CONCLUSIONS

We found no definitive evidence on effectiveness, or lack of effectiveness, of specific interventions but studies were small and short term. People with cognitive impairment and their carers have to tackle eating problems despite this lack of evidence, so promising interventions are listed. The need remains for high quality trials tailored for people with cognitive impairment assessing robust outcomes.

SYSTEMATIC REVIEW REGISTRATION

The systematic review protocol was registered (CRD42014007611) and is published, with the full MEDLINE search strategy, on Prospero.

Identifying Feasible Physical Activity Programs for Long-Term Care Homes in the Ontario Context

Background

Structured exercise programs for frail institutionalized seniors have shown improvement in physical, functional, and psychological health of this population. However, the ‘feasibility’ of implementation of such programs in real settings is seldom discussed. The purpose of this systematic review was to gauge feasibility of exercise and falls prevention programs from the perspective of long-term care homes in Ontario, given the recent changes in funding for publically funded physiotherapy services.

Method

Six electronic databases were searched by two independent researchers for randomized controlled trials that targeted long-term care residents and included exercise as an independent component of the intervention.

Results

A total of 39 studies were included in this review. A majority of these interventions were led by physiotherapist(s), carried out three times per week for 30–45 minutes per session. However, a few group-based interventions that were led by long-term care staff, volunteers, or trained non-exercise specialists were identified that also required minimal equipment.

Conclusion

This systematic review has identified ‘feasible’ physical activity and falls prevention programs that required minimal investment in staff and equipment, and demonstrated positive outcomes. Implementation of such programs represents cost-effective means of providing long-term care residents with meaningful gains in physical, psychological, and social health.

Prevention and optimal management of sarcopenia: a review of combined exercise and nutrition interventions to improve muscle outcomes in older people

The growing recognition of sarcopenia, the age-related loss of skeletal muscle mass and function, has highlighted the need to understand more about its etiology. Declines in muscle mass and strength are expected aspects of aging, but there is significant variability between individuals in rates of loss. Although some of these differences can be explained by fixed factors, such as sex, much of the remaining variation is unexplained. This has led to increasing interest in the influence of adult lifestyle, particularly in the effects of modifiable factors such as physical activity and diet, and in identifying intervention opportunities both to prevent and manage sarcopenia. A number of trials have examined the separate effects of increased exercise or dietary supplementation on muscle mass and physical performance of older adults, but less is known about the extent to which benefits of exercise training could be enhanced when these interventions are combined. In a comprehensive review of the literature, we consider 17 studies of older adults (≥65 years) in which combined nutrition and exercise interventions were used to increase muscle strength and/or mass, and achieve improvements in physical performance. The studies were diverse in terms of the participants included (nutritional status, degree of physical frailty), supplementation strategies (differences in nutrients, doses), exercise training (type, frequency), as well as design (duration, setting). The main message is that enhanced benefits of exercise training, when combined with dietary supplementation, have been shown in some trials – indicating potential for future interventions, but that existing evidence is inconsistent. Further studies are needed, particularly of exercise training combined with dietary strategies that increase intakes of a range of nutrients, as well as bioactive non-nutrients, to provide the evidence on which public health and clinical recommendations can be based.

The effect of protein intake and resistance training on muscle mass in acutely ill old medical patients - A randomized controlled trial

BACKGROUND & AIM

Stress metabolism is associated with accelerated loss of muscle that has large consequences for the old medical patient. The aim of this study was to investigate if an intervention combining protein and resistance training was more effective in counteracting loss of muscle than standard care. Secondary outcomes were changes in muscle strength, functional ability and body weight.

METHODS

29 acutely admitted old (>65 years) patients were randomly assigned to the intervention (n = 14) or to standard care (n = 15). The Intervention Group received 1.7 g protein/kg/day during admission and a daily protein supplement (18.8 g protein) and resistance training 3 times per week the 12 weeks following discharge. Muscle mass was assessed by Dual-energy X-ray Absorptiometry. Muscle strength was assessed by Hand Grip Strength and Chair Stand Test. Functional ability was assessed by the de Morton Mobility Index, the Functional Recovery Score and the New Mobility Score. Changes in outcomes from time of admission to three-months after discharge were analysed by linear regression analysis.

RESULTS

The intention-to-treat analysis showed no significant effect of the intervention on lean mass (unadjusted: β-coefficient = -1.28 P = 0.32, adjusted for gender: β-coefficient = -0.02 P = 0.99, adjusted for baseline lean mass: β-coefficient = -0.31 P = 0.80). The de Morton Mobility Index significantly increased in the Control Group (β-coefficient = -11.43 CI: 0.72-22.13, P = 0.04). No other differences were found.

CONCLUSION

No significant effect on muscle mass was observed in this group of acutely ill old medical patients. High compliance was achieved with the dietary intervention, but resistance training was challenging. Clinical trials identifier NCT02077491.

Sarcopenia: the new definitions

PURPOSE OF REVIEW

To highlight the new international definitions of sarcopenia.

RECENT FINDINGS

New international definitions of sarcopenia have been evaluated and shown to be predictive of poor outcomes in older persons.

SUMMARY

There is now international agreement that the definition for sarcopenia should include not only muscle mass, but also some measure of muscle function, such as walking speed or distance or grip strength.

Maximising functional recovery following hip fracture in frail seniors

This review discusses factors affecting recovery following hip fracture in frail older people as well as interventions associated with improved functional recovery. Prefracture function, cognitive status, co-morbidities, depression, nutrition and social support impact recovery and may interact to affect post-fracture outcome. There is mounting evidence that exercise is beneficial following hip fracture with higher-intensity/duration programmes showing more promising outcomes. Pharmacologic management for osteoporosis has benefits in preventing further fractures, and interest is growing in pharmacologic treatments for post-fracture loss of muscle mass and strength. A growing body of evidence suggests that sub-populations - those with cognitive impairment, residing in nursing homes or males - also benefit from rehabilitation after hip fracture. Optimal post-fracture care may entail the use of multiple interventions; however, more work is needed to determine optimal exercise components, duration and intensity as well as exploring the impact of multimodal interventions that combine exercise, pharmacology, nutrition and other interventions.

Effectiveness of exercise and protein supplementation intervention on body composition, functional fitness, and oxidative stress among elderly Malays with sarcopenia

Sarcopenia, characterized as muscle loss that occurs with aging, is a major health problem in an aging population, due to its implications on mobility, quality of life, and fall risk. Protein supplementation could improve the physical fitness by increasing protein anabolism, and exercise has a documented evidence of positive effect on functional status among the elderly. However, the combined effect of both protein supplementation and exercise has not been investigated among sarcopenic elderly in the Asian population. Thus, this study aimed to determine the effectiveness of exercise intervention and protein supplementation either alone or in combination for 12 weeks, on body composition, functional fitness, and oxidative stress among elderly Malays with sarcopenia. Sixty five sarcopenic elderly Malays aged 60–74 years were assigned to the control group, exercise group (ExG), protein supplementation group (PrG), or the combination of exercise and protein supplementation group. A significant interaction effect between body weight and body mass index (BMI) was observed, with the PrG (−2.1% body weight, −1.8% BMI) showing the highest reductions. Further, there was a decrease in % body fat (−4.5%) and an increase in fat-free mass (kg) (+5.7%) in the ExG after 12 weeks (P < 0.05). The highest increments in lower and upper body strength were observed in the PrG (73.2%) and ExG (47.6%), respectively. In addition, the ExG showed a reduction in superoxide dismutase (SOD) levels, and both interventions did not alter either lipid or protein oxidation. In conclusion, the exercise program was found to improve muscle strength and body composition, while protein supplementation reduced body weight and increased upper body strength, among sarcopenic elderly in Malaysia.

Muscle strength rather than muscle mass is associated with standing balance in elderly outpatients

OBJECTIVES

Assessment of the association of muscle characteristics with standing balance is of special interest, as muscles are a target for potential intervention (ie, by strength training).

DESIGN

Cross-sectional study.

SETTING

Geriatric outpatient clinic.

PARTICIPANTS

The study included 197 community-dwelling elderly outpatients (78 men, 119 women; mean age 82 years).

MEASUREMENTS

Muscle characteristics included handgrip and knee extension strength, appendicular lean mass divided by height squared (ALM/height(2)), and lean mass as percentage of body mass. Two aspects of standing balance were assessed: the ability to maintain balance, and the quality of balance measured by Center of Pressure (CoP) movement during 10 seconds of side-by-side, semitandem, and tandem stance, with both eyes open and eyes closed. Logistic and linear regression models were adjusted for age, and additionally for height, body mass, cognitive function, and multimorbidity.

RESULTS

Handgrip and knee extension strength, adjusted for age, were positively related to the ability to maintain balance with eyes open in side-by-side (P = .011; P = .043), semitandem (P = .005; P = .021), and tandem stance (P = .012; P = .014), and with eyes closed in side-by-side (P = .004; P = .004) and semitandem stance (not significant; P = .046). Additional adjustments affected the results only slightly. ALM/height(2) and lean mass percentage were not associated with the ability to maintain standing balance, except for an association between ALM/height(2) and tandem stance with eyes open (P = .033) that disappeared after additional adjustments. Muscle characteristics were not associated with CoP movement.

CONCLUSION

Muscle strength rather than muscle mass was positively associated with the ability to maintain standing balance in elderly outpatients. Assessment of CoP movement was not of additional value.

Physical rehabilitation for older people in long-term care

BACKGROUND

The worldwide population is progressively ageing, with an expected increase in morbidity and demand for long-term care. Physical rehabilitation is beneficial in older people, but relatively little is known about effects on long-term care residents. This is an update of a Cochrane review first published in 2009.

OBJECTIVES

To evaluate the benefits and harms of rehabilitation interventions directed at maintaining, or improving, physical function for older people in long-term care through the review of randomised and cluster randomised controlled trials.

SEARCH METHODS

We searched the trials registers of the following Cochrane entities: the Stroke Group (May 2012), the Effective Practice and Organisation of Care Group (April 2012), and the Rehabilitation and Related Therapies Field (April 2012). In addition, we searched 20 relevant electronic databases, including the Cochrane Central Register of Controlled Trials (The Cochrane Library, 2009, Issue 4), MEDLINE (1966 to December 2009), EMBASE (1980 to December 2009), CINAHL (1982 to December 2009), AMED (1985 to December 2009), and PsycINFO (1967 to December 2009). We also searched trials and research registers and conference proceedings; checked reference lists; and contacted authors, researchers, and other relevant Cochrane entities. We updated our searches of electronic databases in 2011 and listed relevant studies as awaiting assessment.

SELECTION CRITERIA

Randomised studies comparing a rehabilitation intervention designed to maintain or improve physical function with either no intervention or an alternative intervention in older people (over 60 years) who have permanent long-term care residency.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed risk of bias and extracted data. We contacted study authors for additional information. The primary outcome was function in activities of daily living. Secondary outcomes included exercise tolerance, strength, flexibility, balance, perceived health status, mood, cognitive status, fear of falling, and economic analyses. We investigated adverse effects, including death, morbidity, and other events. We synthesised estimates of the primary outcome with the mean difference; mortality data, with the risk ratio; and secondary outcomes, using vote-counting.

MAIN RESULTS

We included 67 trials, involving 6300 participants. Fifty-one trials reported the primary outcome, a measure of activities of daily living. The estimated effects of physical rehabilitation at the end of the intervention were an improvement in Barthel Index (0 to 100) scores of six points (95% confidence interval (CI) 2 to 11, P = 0.008, seven studies), Functional Independence Measure (0 to 126) scores of five points (95% CI -2 to 12, P = 0.1, four studies), Rivermead Mobility Index (0 to 15) scores of 0.7 points (95% CI 0.04 to 1.3, P = 0.04, three studies), Timed Up and Go test of five seconds (95% CI -9 to 0, P = 0.05, seven studies), and walking speed of 0.03 m/s (95% CI -0.01 to 0.07, P = 0.1, nine studies). Synthesis of secondary outcomes suggested there is a beneficial effect on strength, flexibility, and balance, and possibly on mood, although the size of any such effect is unknown. There was insufficient evidence of the effect on other secondary outcomes. Based on 25 studies (3721 participants), rehabilitation does not increase risk of mortality in this population (risk ratio 0.95, 95% CI 0.80 to 1.13). However, it is possible bias has resulted in overestimation of the positive effects of physical rehabilitation.

AUTHORS' CONCLUSIONS

Physical rehabilitation for long-term care residents may be effective, reducing disability with few adverse events, but effects appear quite small and may not be applicable to all residents. There is insufficient evidence to reach conclusions about improvement sustainability, cost-effectiveness, or which interventions are most appropriate. Future large-scale trials are justified.

Protein supplementation improves physical performance in frail elderly people: a randomized, double-blind, placebo-controlled trial

OBJECTIVES

Protein supplementation has been proposed as an effective dietary strategy to increase skeletal muscle mass and improve physical performance in frail elderly people. Our objective was to assess the impact of 24 weeks of dietary protein supplementation on muscle mass, strength, and physical performance in frail elderly people.

DESIGN/SETTING/PARTICIPANTS

A total of 65 frail elderly subjects were included and randomly allocated to either daily protein or placebo supplementation (15 g protein at breakfast and lunch).

MEASUREMENTS

Skeletal muscle mass (DXA), muscle fiber size (muscle biopsy), strength (1-RM), and physical performance (SPPB) were assessed at baseline, and after 12 and 24 weeks of dietary intervention.

RESULTS

Skeletal muscle mass did not change in the protein- (from 45.8 ± 1.7 to 45.8 ± 1.7 kg) or placebo-supplemented group (from 46.7 ± 1.7 to 46.6 ± 1.7 kg) following 24 weeks of intervention (P > .05). In accordance, type I and II muscle fiber size did not change over time (P > .05). Muscle strength increased significantly in both groups (P < .01), with leg extension strength tending to increase to a greater extent in the protein (57 ± 5 to 68 ± 5 kg) compared with the placebo group (57 ± 5 to 63 ± 5 kg) (treatment × time interaction effect: P = .059). Physical performance improved significantly from 8.9 ± 0.6 to 10.0 ± 0.6 points in the protein group and did not change in the placebo group (from 7.8 ± 0.6 to 7.9 ± 0.6 points) (treatment × time interaction effect: P = .02).

CONCLUSION

Dietary protein supplementation improves physical performance, but does not increase skeletal muscle mass in frail elderly people.

Protein supplementation increases muscle mass gain during prolonged resistance-type exercise training in frail elderly people: a randomized, double-blind, placebo-controlled trial

OBJECTIVES

Protein supplementation has been proposed as an effective dietary strategy to augment the skeletal muscle adaptive response to prolonged resistance-type exercise training in elderly people. Our objective was to assess the impact of protein supplementation on muscle mass, strength, and physical performance during prolonged resistance-type exercise training in frail elderly men and women.

DESIGN/SETTING/PARTICIPANTS

A randomized, double-blind, placebo-controlled trial with 2 arms in parallel among 62 frail elderly subjects (78 ± 1 year). These elderly subjects participated in a progressive resistance-type exercise training program (2 sessions per week for 24 weeks) during which they were supplemented twice daily with either protein (2 * 15 g) or a placebo.

MEASUREMENTS

Lean body mass (DXA), strength (1-RM), and physical performance (SPPB) were assessed at baseline, and after 12 and 24 weeks of intervention.

RESULTS

Lean body mass increased from 47.2 kg (95% CI, 43.5-50.9) to 48.5 kg (95% CI, 44.8-52.1) in the protein group and did not change in the placebo group (from 45.7 kg, 95% CI, 42.1-49.2 to 45.4 kg, 95% CI, 41.8-48.9) following the intervention (P value for treatment × time interaction = .006). Strength and physical performance improved significantly in both groups (P = .000) with no interaction effect of dietary protein supplementation.

CONCLUSIONS

Prolonged resistance-type exercise training represents an effective strategy to improve strength and physical performance in frail elderly people. Dietary protein supplementation is required to allow muscle mass gain during exercise training in frail elderly people.

TRIAL REGISTRATION

clinicaltrials.gov identifier: NCT01110369.

Physiological effects beyond the significant gain in muscle mass in sarcopenic elderly men: evidence from a randomized clinical trial using a protein-rich food

BACKGROUND

Sarcopenia is strongly associated with an inadequate intake of dietary protein. Dietary protein supplementation boosts muscle-protein synthesis and increases muscle mass in the elderly. This study tested whether adding a protein-rich food, ricotta cheese, to the habitual diet increased total appendicular skeletal muscle mass and strength in elderly people.

METHODS

Participants (n = 40), were sarcopenic elderly men and women over 60 years of age. Two comparison groups were formed at random and followed for 3 months: the intervention group received 210 g/day of ricotta cheese plus the habitual diet, while the control group followed the habitual diet with no additional intervention. Total appendicular skeletal muscle (TASM) was assessed by dual-energy X-ray absorptiometry, while strength was measured using a handheld dynamometer at baseline and after the intervention period. The primary outcomes were the percentage of relative change in TASM and strength.

RESULTS

The percentage of relative change in TASM was not significant between the groups after the intervention period. Muscle strength improved in the intervention group, but showed only a tendency towards significance (P = 0.06). Secondary analysis showed that the men in the intervention group gained 270 g in TASM compared to those in the control group, and improved their fasting insulin levels (P = 0.05), muscle strength, lean body mass in the arms, and body weight variables.

CONCLUSION

The results of this study indicate that a nutritional intervention using a high-quality protein food, specifically ricotta cheese, in order to increase the amount of protein intake might not be regarded as fully promising in elderly men and women with sarcopenia. However, the gender effects on muscle strength, lean tissue in the arms, homeostatic assessment of insulin resistance, and body weight detected in this study suggest that additional research is needed on elderly male subjects with sarcopenia.