Exercise Deficiency Diseases of Ageing: The Primacy of Exercise and Muscle Strengthening as First-Line Therapeutic Agents to Combat Frailty

Physical enhancement of older adults using hyperbaric oxygen: a randomized controlled trial

INTRODUCTION

Aging is associated with a progressive decline in the capacity for physical activity. The objective of the current study was to evaluate the effect of an intermittent hyperbaric oxygen therapy (HBOT) protocol on maximal physical performance and cardiac perfusion in sedentary older adults.

METHODS

A randomized controlled clinical trial randomized 63 adults (> 64yrs) either to HBOT (n = 30) or control arms (n = 33) for three months. Primary endpoint included the maximal oxygen consumption (VO2Max) and VO2Max/Kg, on an E100 cycle ergometer. Secondary endpoints included cardiac perfusion, evaluated by magnetic resonance imaging and pulmonary function. The HBOT protocol comprised of 60 sessions administered on a daily basis, for 12 consecutive weeks, breathing 100% oxygen at 2 absolute atmospheres (ATA) for 90 min with 5-minute air breaks every 20 min.

RESULTS

Following HBOT, improvements were observed in VO2Max/kg, with a significant increase of 1.91 ± 3.29 ml/kg/min indicated by a net effect size of 0.455 (p = 0.0034). Additionally, oxygen consumption measured at the first ventilatory threshold (VO2VT1) showed a significant increase by 160.03 ± 155.35 ml/min (p < 0.001) with a net effect size of 0.617. Furthermore, both cardiac blood flow (MBF) and cardiac blood volume (MBV) exhibited significant increases when compared to the control group. The net effect size for MBF was large at 0.797 (p = 0.008), while the net effect size for MBV was even larger at 0.896 (p = 0.009).

CONCLUSION

The findings of the study indicate that HBOT has the potential to improve physical performance in aging adults. The enhancements observed encompass improvements in key factors including VO2Max, and VO2VT1. An important mechanism contributing to these improvements is the heightened cardiac perfusion induced by HBOT.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT02790541 (registration date 06/06/2016).

A Practice Guide for Physical Therapists Prescribing Physical Exercise for Older Adults

INTRODUCTION

Physical activity and exercise are protective factors for physical and cognitive decline in older adults, but recent studies reveal that a large percentage of this population do not practice exercise at the levels recommended by international guidelines. The frequency, intensity, type, time, volume, and progression (FITT-VP) principles are a widely used method for prescribing physical exercise, allowing the development of a personalized exercise program that meets the needs of each individual.

OBJECTIVES

This masterclass is intended to serve as a professional application tool for physical therapists who prescribe physical exercise for older adults. We present a section for each FITT-VP principle to facilitate handling these principles individually when prescribing exercise for this population.

METHODS

Review of the scientific literature and international guidelines on the prescription of physical exercises for older adults.

RESULTS

Aerobic, mobility, resistance, balance, and flexibility exercises, as well as functional training, should be included in an exercise program for older adults, which should be progressed using different methods for each of the exercise modalities.

CONCLUSIONS

An exercise program for older adults should integrate different exercise modalities. Exercise progression should be performed following the FITT-VP principles and some specific progression factors recommended for each exercise modality.

SIGNIFICANCE

Considering the challenge faced by clinicians in designing a viable exercise program for older adults that responds to international recommendations, with this masterclass we hope to help physical therapists to plan an exercise program that is feasible and at the same time, responds to the expected needs of this population.

Validation of a polygenic risk score for frailty in the Lothian Birth Cohort 1936 and English longitudinal study of ageing

Frailty is a complex trait. Twin studies and high-powered Genome Wide Association Studies conducted in the UK Biobank have demonstrated a strong genetic basis of frailty. The present study utilized summary statistics from a Genome Wide Association Study on the Frailty Index to create and test the predictive power of frailty polygenic risk scores (PRS) in two independent samples - the Lothian Birth Cohort 1936 (LBC1936) and the English Longitudinal Study of Ageing (ELSA) aged 67-84 years. Multiple regression models were built to test the predictive power of frailty PRS at five time points. Frailty PRS significantly predicted frailty, measured via the FI, at all-time points in LBC1936 and ELSA, explaining 2.1% (β = 0.15, 95%CI, 0.085-0.21) and 1.8% (β = 0.14, 95%CI, 0.10-0.17) of the variance, respectively, at age ~ 68/ ~ 70 years (p < 0.001). This work demonstrates that frailty PRS can predict frailty in two independent cohorts, particularly at early ages (~ 68/ ~ 70). PRS have the potential to be valuable instruments for identifying those at risk for frailty and could be important for controlling for genetic confounders in epidemiological studies.

Frontiers in sarcopenia: Advancements in diagnostics, molecular mechanisms, and therapeutic strategies

The onset of sarcopenia is intimately linked with aging, posing significant implications not only for individual patient quality of life but also for the broader societal healthcare framework. Early and accurate identification of sarcopenia and a comprehensive understanding of its mechanistic underpinnings and therapeutic targets paramount to addressing this condition effectively. This review endeavors to present a cohesive overview of recent advancements in sarcopenia research and diagnosis. We initially delve into the contemporary diagnostic criteria, specifically referencing the European Working Group on Sarcopenia in Older People (EWGSOP) 2 and Asian Working Group on Sarcopenia (AWGS) 2019 benchmarks. Additionally, we elucidate comprehensive assessment techniques for muscle strength, quantity, and physical performance, highlighting tools such as grip strength, chair stand test, dual-energy X-ray Absorptiometry (DEXA), bioelectrical impedance analysis (BIA), gait speed, and short physical performance battery (SPPB), while also discussing their inherent advantages and limitations. Such diagnostic advancements pave the way for early identification and unequivocal diagnosis of sarcopenia. Proceeding further, we provide a deep-dive into sarcopenia's pathogenesis, offering a thorough examination of associated signaling pathways like the Myostatin, AMP-activated protein kinase (AMPK), insulin/IGF-1 Signaling (IIS), and the nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB) pathways. Each pathway's role in sarcopenia mediation is detailed, underscoring potential therapeutic target avenues. From a mechanistic perspective, the review also underscores the pivotal role of mitochondrial dysfunction in sarcopenia, emphasizing elements such as mitochondrial oxidative overload, mitochondrial biogenesis, and mitophagy, and highlighting their therapeutic significance. At last, we capture recent strides made in sarcopenia treatment, ranging from nutritional and exercise interventions to potential pharmacological and supplementation strategies. In sum, this review meticulously synthesizes the latest scientific developments in sarcopenia, aiming to enhance diagnostic precision in clinical practice and provide comprehensive insights into refined mechanistic targets and innovative therapeutic interventions, ultimately contributing to optimized patient care and advancements in the field.

An Investigation of the Sled-Push Exercise Using a Resisted Sled Machine in Apparently Healthy Older Adults: An Exploratory Study

Physical function is regarded as the cornerstone of healthy aging, and exercise is an important determinant of healthy aging. This study examined the feasibility and physiological (heart rate, blood pressure, blood lactate, and rate of perceived exertion) and psychological (enjoyment) response resulting from an acute progressive sled-push (SLP) exercise session using the novel XPO Sled Trainer in older adults and compared that with walking (WKC) condition. The exercise session comprised six exercise bouts at 75%, 85%, 100% (2×), and 125% (2×) of normal velocity with a 2-min rest between bouts. Thirty-six older adults were randomly allocated into either the SLP or WKC conditions. No adverse events were observed during the exercise session, and all participants completed the exercise protocol as prescribed. One-third of the participants in the SLP group reported minimal body discomfort. Significantly higher responses were observed for all physiological variables as the intensity of the exercise increased in the SLP group compared with the WKC group (p < .001). The SLP group presented a decline in enjoyment as the intensity of the exercise increased (during), but similar enjoyment level than the WKC group for the overall exercise session (p = .711). Our findings support the viability and safety of SLP exercise using the XPO Sled Trainer in older adults. Such exercise demonstrated an intensity-driven modality that may have potential to elucidate positive adaptations in the cardiovascular system of older adults with acceptable levels of enjoyment.

The Perspective of Rehabilitation Nurses on Physical Exercise in the Rehabilitation of Older People in the Community: A Qualitative Study

In the face of an increasingly aging population, nurses have to design and implement programs aimed at the elderly in order to keep them healthy and maintain their quality of life. Structured physical exercise and overall physical activity play a major role in maintaining an active lifestyle, improving health, preventing disease, and helping to maintain older people's quality of life. To investigate the importance of implementing physical exercise programs for the older person in the community, taking into account the perspective of the rehabilitation nurse specialist, this is a qualitative, exploratory, and descriptive study with nine rehabilitation nurses from various regions of Portugal who have experience of implementing physical exercise programs with the elderly. This study used semi-structured interviews, one of the most common data collection procedures in social and health research. Content analysis was used to analyze the data. The study received a positive opinion from the Ethics Committee. The participants' perspectives focused on the following subjects: "Physical exercise program for the elderly in the community", "Importance of physical exercise in the rehabilitation of the elderly in the community", "People's adherence to the programs", "Gains in health resulting from the implementation of these strategies" and "Gains from group activities". A set of indicators emerged from the analysis. Nurses recognize the importance of using structured physical exercise programs adjusted to the rehabilitation of the older person, with gains in promoting active and healthy aging.

The effectiveness of nurse-led interventions to manage frailty in community-dwelling older people: a systematic review

BACKGROUND

The global increase in the number of frail older people and the accompanying increase in chronic conditions underline the need to develop effective health promotion and preventive interventions for these population groups. Wide ranging of physical, psychological, and social health factors influence frailty in older people and leads to increased vulnerability to many adverse outcomes. To reverse or reduce the progression of frailty, nurses play a pivotal role in delivering health promotion and preventive interventions. The purpose of the review is to determine the effectiveness of nurse-led interventions in reducing frailty in community-dwelling older people.

METHODS

The following electronic databases: PubMed, MEDLINE, Web of Science, SCOPUS, CINAHL, PsychInfo, and WHO Global Index Medicus were searched until June 2022. Nurse-led, "nurse led", education, training, intervention, program, teaching, frail*, fragile*, "frailty syndrome", debility, infirmity, elder*, aged*, old*, geriatric, "community based settings", "community-based", "community setting", community were the search terms. Before data extraction, eligible articles were assessed for their methodological quality. The JBI critical appraisal checklist for reporting experimental studies was utilised to appraise the methodological quality of the studies. Data were systematically examined using a narrative review to determine the effectiveness of the intervention.

RESULTS

Of the 156 studies identified, from the search, six studies with samples ranging from 40 to 1387 older people were eligible for inclusion in the review. Two quasi-experimental studies and one Randomised Controlled Trial (RCT) showed a moderate risk of bias. The Nurse-led frailty interventions used a multi-component intervention approach across the studies. The interventions reversed frailty progression, improve physical functioning, nutritional status, and quality of life, enhance perceptions of social support, improve mental health, and reduce depression.

CONCLUSIONS

Few studies have explored the effectiveness of a nurse-led intervention to decrease frailty in older people. Evaluating physical functioning, nutritional status, mental health, and quality of life in community-dwelling frail older people can contribute to developing appropriate interventions.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO ID of CRD42022348064.

Promoting resilience in the face of ageing and disease: The central role of exercise and physical activity

Exercise and physical activity offer clinical benefits across a wide range of both physical and neuropsychological diseases and disabilities in older adults, including syndromes for which pharmacological treatment is either absent or hazardous. However, exercise is vastly under-utilised and rarely fully integrated into aged care and geriatric medicine practice. It is still absent from the core training of most geriatricians and other healthcare professionals, and myths about risks of robust exercise abound. Insufficient physical activity and sedentariness are in fact the lethal conditions. Frailty is not a barrier to exercise, but rather one of the most important reasons to prescribe it. Like any other medical treatment, to prescribe exercise as a drug will require a full understanding of its benefits, dose-response characteristics, modality-specific adaptations, potential risks, and interactions with other treatments. Additionally, exercise prescription should be a mandatory component of training for all healthcare professionals in geriatric medicine and gerontology. This personal view asserts the importance of medication management closely integrated with physical exercise prescription, as well as nutritional support as cornerstone of a coherent and holistic approach to treating both fit and frail older adults. This includes identification and management of drug-exercise interactions, in the same way that we seek out and manage drug-drug interactions and drug-nutrient interactions. Our oldest patients deserve the dignity of our urgent resolve to remember the mission of medicine: the assertion and the assurance of the human potential. Exercise medicine is core to this mission.

Validation of a polygenic risk score for Frailty in the Lothian Birth Cohort and English Longitudinal Study of Ageing

Frailty is a complex trait. Twin studies and a high-powered Genome Wide Association Study (GWAS) conducted in the UK Biobank have demonstrated a strong genetic basis of frailty. The present study utilized summary statistics from this GWAS to create and test the predictive power of frailty polygenic risk scores (PRS) in two independent samples - the Lothian Birth Cohort 1936 (LBC1936) and the English Longitudinal Study of Ageing (ELSA) aged 67-84 years. Multiple regression models were built to test the predictive power of frailty PRS at five time points. Frailty PRS significantly predicted frailty at all-time points in LBC1936 and ELSA, explaining 2.1% (β = 0.15, 95%CI, 0.085-0.21) and 1.6% (β = 0.14, 95%CI, 0.10-0.17) of the variance, respectively, at age ~68/~70 years (p < 0.001). This work demonstrates that frailty PRS can predict frailty in two independent cohorts, particularly at early ages (~68/~70). PRS have the potential to be valuable instruments for identifying those at risk for frailty and could be important for controlling for genetic confounders in epidemiological studies.

Characteristics and effects of physical exercise programs for older adults during the COVID-19 pandemic: an integrative review

Objective: To evaluate the characteristics of physical exercise programs for older adults and their effects during the COVID-19 pandemic. Methods: An integrative review was conducted between January and March 2022. A search was conducted in MEDLINE via PubMed, Lilacs via BVS, PEDro, and Cochrane Library. Experimental articles (randomized clinical trials, non-randomized trials, or quasi-experimental studies) published from 2019 to 2021, with no language restriction, and that used physical exercise programs for older adults (> 60 years) in their intervention were included. The studies were selected by reading the title, abstract, and full text. The selected articles had their results extracted using an online form, tabulated using an electronic spreadsheet, and analyzed qualitatively and quantitatively. Results: 113 studies were identified; 7 met the eligibility criteria and were included in the review, all randomized controlled trials. The multi-component exercise programs were more frequent (resistance, balance, flexibility, and aerobic), delivered remotely and performed 2 to 7 times a week, lasting between 30 and 50 minutes. Significant effects were observed on physical function, body composition, blood triglycerides, the incidence of falls, physical activity, and functional capacity. Conclusions: The physical exercise programs used during the COVID-19 pandemic showed promising results for older adults. The programs proved to be a viable alternative for maintaining the physical, mental, and cognitive functions of older adults in times of public calamity.

The effects of a moderate physical activity intervention on physical fitness and cognition in healthy elderly with low levels of physical activity: a randomized controlled trial

BACKGROUND

Increasing physical activity is one of the most promising and challenging interventions to delay or prevent cognitive decline and dementia.

METHODS

We conducted a randomized controlled trial to assess the effects of a physical activity intervention, aimed at increasing step count, in elderly with low levels of physical activity on measures of strength, balance, aerobic capacity, and cognition. Participants were assigned to 9 months of exercise counseling or active control.

RESULTS

The intention-to-treat analyses show that the intervention, compared to control, increases the level of physical activity, but has no significant effect on physical fitness and cognition. Those who increased their physical activity with 35% or more show significant improvements in aerobic capacity, gait speed, verbal memory, executive functioning, and global cognition, compared to those who did not achieve a 35% increase.

LIMITATIONS

The number of participants that achieved the intended improvement was lower than expected.

CONCLUSION

Responder analyses suggest an improvement of physical fitness and cognition in those who achieved an increase in physical activity of at least 35%.

TRIAL REGISTRATION

The trial protocol is registered at the Dutch Trial Register NL5675, August 1, 2016.

Cost-Consequences Analysis Following Different Exercise Interventions in Institutionalized Oldest Old: A Pilot Study of a Randomized Clinical Trial

OBJECTIVES

to investigate the effects of two different exercise interventions on cost of care, functional capacity, falls occurrence, muscle strength, and executive function in institutionalized oldest old.

DESIGN

A pilot study of a randomized clinical trial investigating 12 months of two exercise interventions compared to a usual care group in oldest old residents of a nursing home.

SETTING AND PARTICIPANTS

69 older patients (mean age 89.4 ±5.1 years) completed the full baseline and post intervention measurements. Participants were randomly allocated into multicomponent exercise group (MG, n=23), calisthenics group (CALG, n = 23), and usual care group (UCG, n=23).

METHODS

Primary outcome was individual cost of care, and secondary outcomes included different physical and cognitive functioning tests, as well as number of falls.

RESULTS

MG reduced the cost of care compared to the pre-intervention period, with the greatest difference from baseline achieved in month 12 [mean change 95% confidence interval (CI)=-330.43 (-527.06, -133.80), P=0.006], while UCG increased this outcome, with the greatest difference from baseline observed in month 12 [mean change (95%CI)=300.00 (170.27, 429.72), P=0.013]. In addition, MG significantly improved SPPB score [mean change (95% CI) = 1.21 (0.55, 1.88), P<0.001], whereas the UCG exhibited a decline in scores [mean change (95% CI) = -1.43 (-1.90, -0.97), P<0.001]. Moreover, MG group demonstrated an improvement in the number of falls [mean change (CI 95%) = -1.0 (-1.73, -0.27), P=0.003], while no significant changes were observed in UCG. Additionally, MG exhibited a significant increase in the handgrip strength (HGS) and leg press strength (P<0.001), while a decrease was observed in UCG (P<0.001). No significant changes were observed in the CALG.

CONCLUSIONS AND IMPLICATIONS

a one-year multicomponent exercise intervention reduced the cost of care, improved functional capacity and muscle strength, as well as reduced falls in institutionalized oldest old.

"If somebody had told me I'd feel like I do now, I wouldn't have believed them…" older adults' experiences of the BELL trial: a qualitative study

Objectives

This study examined older adults’ experiences of participating in the Ballistic Exercise of the Lower Limb (BELL) trial, involving 12-weeks of group-based hardstyle kettlebell training.

Methods

In the BELL trial, 28 insufficiently active older adults (15 women, 13 men, 59–79 years) completed six weeks of face-to-face group training, and six weeks of home-based training. In-depth semi-structured interviews were audio recorded, transcribed, and inductively coded, with themes constructed from patterns of shared meaning.

Results

Four higher-order themes were developed that reflect older adults’ experiences participating in a group-exercise program of hardstyle kettlebell training. These included: (1) “It’s one of the best things we’ve done”—enjoying the physical and psychosocial benefits, (2) “It’s improved it tremendously!”—change in a long-term health condition, (3) “It put me on a better course”—overcoming challenges, and (4) “I wasn’t just a number”—feeling part of a group/community.

Discussion

Findings highlight the perceived physical and psychological benefits of older adults participating in hardstyle group kettlebell training, and the value attributed to being part of an age-matched community of like-minded people engaged in group exercise. Implications for program design and delivery, and future research, are discussed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03174-5.

Effects of Vivifrail multicomponent intervention on functional capacity: a multicentre, randomized controlled trial

BACKGROUND

Physical exercise is an effective strategy for preserving functional capacity and improving the symptoms of frailty in older adults. In addition to functional gains, exercise is considered to be a cornerstone for enhancing cognitive function in frail older adults with cognitive impairment and dementia. We assessed the effects of the Vivifrail exercise intervention for functional capacity, cognition, and well-being status in community-dwelling older adults.

METHODS

In a multicentre randomized controlled trial conducted in three tertiary hospitals in Spain, a total of 188 older patients with mild cognitive impairment or mild dementia (aged >75 years) were randomly assigned to an exercise intervention (n = 88) or a usual-care, control (n = 100) group. The intervention was based on the Vivifrail tailored multicomponent exercise programme, which included resistance, balance, flexibility (3 days/week), and gait-retraining exercises (5 days/week) and was performed for three consecutive months (http://vivifrail.com). The usual-care group received habitual outpatient care. The main endpoint was change in functional capacity from baseline to 1 and 3 months, assessed with the Short Physical Performance Battery (SPPB). Secondary endpoints were changes in cognitive function and handgrip strength after 1 and 3 months, and well-being status, falls, hospital admission rate, visits to the emergency department, and mortality after 3 months.

RESULTS

The Vivifrail exercise programme provided significant benefits in functional capacity over usual-care. The mean adherence to the exercise sessions was 79% in the first month and 68% in the following 2 months. The intervention group showed a mean increase (over the control group) of 0.86 points on the SPPB scale (95% confidence interval [CI] 0.32, 1.41 points; P < 0.01) after 1 month of intervention and 1.40 points (95% CI 0.82, 1.98 points; P < 0.001) after 3 months. Participants in the usual-care group showed no significant benefit in functional capacity (mean change of -0.17 points [95% CI -0.54, 0.19 points] after 1 month and -0.33 points [95% CI -0.70, 0.04 points] after 3 months), whereas the exercise intervention reversed this trend (0.69 points [95% CI 0.29, 1.09 points] after 1 month and 1.07 points [95% CI 0.63, 1.51 points] after 3 months). Exercise group also obtained significant benefits in cognitive function, muscle function, and depression after 3 months over control group (P < 0.05). No between-group differences were obtained in other secondary endpoints (P > 0.05).

CONCLUSIONS

The Vivifrail exercise training programme is an effective and safe therapy for improving functional capacity in community-dwelling frail/prefrail older patients with mild cognitive impairment or mild dementia and also seems to have beneficial effect on cognition, muscle function, and mood status.

Analysis of readmissions data among frail and non-frail patients presenting for acoustic neuroma

The incidence of acoustic neuromas in the United States is 1.09 per 100,000 with 23,739 newly diagnosed cases in the years 2004 to 2010. Because the recent literature has supported that frailty can serve as a more accurate predictor of patient outcomes when evaluated with age, and is an important variable to consider in the course of patient treatment. The objective of this study was to compare the outcomes of frail patients who had undergone surgery for acoustic neuroma with their non-frail counterparts.The authors conducted a retrospective cohort study of geriatric patients receiving cranial neurosurgery for acoustic neuroma between 2016 and 2017 by using the Nationwide Readmission Database. A total of 396 frail patients and 402 non-frail patients were identified through the database of undergoing surgery for acoustic neuroma. Frail patients had statistically higher rates of readmission (p < 0.01), post-operative infection (p < 0.01), facial paralysis (p < 0.01), urinary tract infection (p < 0.01), hydrocephalus (p < 0.01), and dysphagia (p < 0.01). These post-op morbidities likely led to the increased length of stay (p < 0.01), non-routine discharge (p < 0.01), and all payer cost seen in frail patients (p < 0.01). However, no significant difference was found between frail and non-frail patients with regards to CSF leak, post hemorrhagic anemia, myocardial infarction, and mortality. Patient frailty status is a significant predictor of poor outcomes in the postoperative sequelae of acoustic neuroma surgery. Further, models including patient frailty plus age outperformed those using age alone for prediction of several postoperative complications.

A Hypothesis: The Interplay of Exercise and Physiological Heterogeneity as Drivers of Human Ageing

As the inherent ageing process affects every facet of biology, physiology could be considered as the study of the healthy human ageing process. Where biological health is affected by lifestyle, the continual and continuing interaction of this process with physical activity and other lifestyle choices determine whether the ageing trajectory is toward health or disease. The presentation of both these states is further modified in individuals by the interaction of inherent physiological heterogeneity and the heterogeneity associated with responses and adaptions to exercise. The range of heterogeneity in healthy physiology is circumscribed by the necessity to conform to that of the human species. Our hypothesis is that, when sufficient exercise is present, these multiple interactions appear to produce an ageing profile that, while functional ability is in decline, remains synchronous, coherent, and integrated throughout most of life. In the absence of sufficient physical activity, physiology over time is gradually deteriorating toward the production of a lifestyle disease. Here, the ageing process, interacting with individual physiological heterogeneity, probably determines the age of presentation of a disease as well as the order of presentation of subsequent diseases. In this article, we discuss this hypothesis and related concepts in the context of the trajectory of healthy and non-healthy human ageing.

Promoting neuroplasticity and neuropsychological functioning in frailty through an app-based sensorimotor training: study protocol for a randomized trial

BACKGROUND

Frailty is characterized by an age-related decline in multiple physiological systems, leading to a high vulnerability to stressors, adverse health outcomes, and low quality of life. Neuroscientific models of pathological aging emphasize the loss of sensorimotor stimulation and reduced neuromodulatory capacities as core processes in age-related cognitive and bodily decline, which may be associated with maladaptive plastic changes in the brain. We plan to increase sensorimotor stimulation in frail persons through a newly developed app-based training program and link the training trials to biological and psychological correlates of age-associated vulnerability and health indices.

METHODS

We will conduct a randomized trial, applying an app-based sensorimotor home training (N = 30) in people suffering from frailty. An app-based relaxation training will serve as an active control condition (N = 30). Both interventions will last for 90 days each. The sensorimotor training includes unimodal and multimodal sensory discrimination tasks in the visual, auditory, and tactile domain, as well as sensorimotor precision tasks. The tasks will be implemented using an adaptive training algorithm and enriched with motivational components embedded in a virtual training environment. We expect a pre-post reduction of frailty status and associated functional decline related to refinement of representational maps within the sensorimotor system and improved sensorimotor function such as extremity function. Secondary analyses will study the influence of BDNF genotype as moderating variable. Additional outcomes will include measures of perceptual and cognitive functioning, quality of life as well as BDNF serum levels. Measurements will take place before training (baseline), after 60 days (assessment 1), and at the end of the training after 90 days (assessment 2).

DISCUSSION

In our randomized trial, we aim to characterize a multidimensional concept of frailty and to target maladaptive behaviors and neuroplasticity using an app-based sensorimotor training. This type of intervention might provide further knowledge and new possibilities for preventing decline and preserving function in older adults.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03666039 . Registered 11 September 2018 - Retrospectively registered. Protocol version: Version 4 revised (issue date: 19 May 2021).

BandPass: A Bluetooth-Enabled Remote Monitoring Device for Sarcopenia

As the United States population ages, managing pathologies that largely affect older adults, including sarcopenia (i.e., loss of muscle mass and strength) represents a significant and growing clinical challenge. In addition to increased rates of sarcopenia with age, its incidence and impact increase after acute illness, increasing the risk of functional decline, institutionalization, or death. Resistance-based exercises promote muscle regeneration and strength and are an advised therapy for such patients. Yet, such therapeutic exercises are normally conducted either under direct clinical oversight or unsupervised by patients at home, where compliance rates are low. The presented device, BandPass, aims to create an integrated force data detection and acquisition system for monitoring and transmitting at-home exercise force data to patients and clinicians. A potentiometer-based sensor was integrated to a resistance exercise band through the use of custom designed electronics, which incorporated Bluetooth Low Energy (BLE) for wireless transmission to a mobile 'app'. A protocol for calibrating the device was developed using a range of loads and validated in static benchtop and dynamic testing. Data from a pilot study with 7 older adults was also collected and analyzed to test the device. BandPass is 94% accurate with a coefficient of variation (CoV) of 4.9% and sensitivity of 150g. The pilot study recorded 147 exercises, allowing for analysis on patients' exercise performances. BandPass was successfully able to measure force continuously over time during exercises, measure longitudinal compliance with exercises, and quantify force continuously over time. A mobile health (mHealth) force-sensing system allows for the remote monitoring of prescribed in-home resistance exercise band programs for at-risk older adults, bridging the gap between clinicians and patients.

Lifelong Endurance Exercise as a Countermeasure Against Age-Related [Formula: see text] Decline: Physiological Overview and Insights from Masters Athletes

Maximum oxygen consumption ([Formula: see text]) is not only an indicator of endurance performance, but also a strong predictor of cardiovascular disease and mortality. This physiological parameter is known to decrease with aging. In turn, physical exercise might attenuate the rate of aging-related decline in [Formula: see text], which in light of the global population aging is of major clinical relevance, especially at advanced ages. In this narrative review, we summarize the evidence available from masters athletes about the role of lifelong endurance exercise on aging-related [Formula: see text] decline, with examples of the highest [Formula: see text] values reported in the scientific literature for athletes across different ages (e.g., 35 ml·kg^-1·min^-1 in a centenarian cyclist). These data suggest that a linear decrease in [Formula: see text] might be possible if physical exercise loads are kept consistently high through the entire life span, with [Formula: see text] values remaining higher than those of the general population across all ages. We also summarize the main physiological changes that occur with inactive aging at different system levels-pulmonary and cardiovascular function, blood O₂ carrying capacity, skeletal muscle capillary density and oxidative capacity-and negatively influence [Formula: see text], and review how lifelong exercise can attenuate or even prevent most-but apparently not all (e.g., maximum heart rate decline)-of them. In summary, although aging seems to be invariably associated with a progressive decline in [Formula: see text], maintaining high levels of physical exercise along the life span slows the multi-systemic deterioration that is commonly observed in inactive individuals, thereby attenuating age-related [Formula: see text] decline.

Benefits of STRENOLD Program on Health-Related Quality of Life in Adults Aged 60 Years or Older. In Common Sport Study

Background: The proportion of older adults is increasing worldwide and, with it, the physical inactivity common to this age group. Therefore, the promotion of active aging is a strategic factor in health policies for older people. The aim of this study was to identify the benefits and viability of the strength training program (STRENOLD) in health-related quality of life in adults over 60. Methods: A controlled experimental study was carried out with a sample of 181 people over 60 years old from different European countries belonging to the European project IN COMMON SPORTS. A pair work strength program was administered (STRENOLD) over a period of 24 months, consisting of two single sessions per week. Their health status was evaluated (EQ-5D-5L) before and after the interventions. Results: The adherence rate was over 89% and the tolerability rate over 100% in all participating countries. Significant improvements in the participants’ health were demonstrated in the areas of mobility, usual activities, pain/discomfort, and anxiety/depression. Conclusions: The regular practice of physical exercise, through the partnered STRENOLD strength program, has benefits on mobility, usual activities, pain/discomfort, and anxiety/depression, in short, health benefits for older adults.

Effects of 6-Month Multimodal Physical Exercise Program on Bone Mineral Density, Fall Risk, Balance, and Gait in Patients with Alzheimer's Disease: A Controlled Clinical Trial

We aimed to determine the short- and medium-term effects of a multimodal physical exercise program (MPEP) on bone health status, fall risk, balance, and gait in patients with Alzheimer’s disease. A single-blinded, controlled clinical trial was performed where 72 subjects were allocated in a 3:1 ratio to an intervention group (IG; n = 53) and control group (CG; n = 19), where the IG’s subjects were admitted to live in a State Reference Center of Alzheimer’s disease, which offers the targeted exercise program, while the CG’s subjects resided in independent living. A multidisciplinary health team assessed all patients before allocation, and dependent outcomes were again assessed at one, three, and six months. During the study, falls were recorded, and in all evaluations, bone mineral density was measured using a calcaneal quantitative ultrasound densitometer; balance and gait were measured using the performance-oriented mobility assessment (POMA), the timed up and go test (TUG), the one-leg balance test (OLB), and the functional reach test (FR). There were no differences between groups at baseline for all outcome measures. The prevalence of falls was significantly lower in the IG (15.09%) than in the CG (42.11%) (χ² = 5.904; p = 0.015). We also found that there was a significant time*group interaction, with a post hoc Šidák test finding significant differences of improved physical function, especially in gait, for the IG, as assessed by POMA-Total, POMA-Gait, and TUG with a large effect size (ƞ²p = 0.185–0.201). In balance, we found significant differences between groups, regardless of time, and a medium effect size as assessed by POMA-Balance and the OLB (ƞ²p = 0.091–0.104). Clinically relevant effects were observed, although without significant differences in bone health, with a slowing of bone loss. These results show that a multimodal physical exercise program reduces fall risk and produces an improvement in gait, balance, and bone mineral density in the short and medium term in institutionalized patients with Alzheimer’s disease.

International Exercise Recommendations in Older Adults (ICFSR): Expert Consensus Guidelines

The human ageing process is universal, ubiquitous and inevitable. Every physiological function is being continuously diminished. There is a range between two distinct phenotypes of ageing, shaped by patterns of living - experiences and behaviours, and in particular by the presence or absence of physical activity (PA) and structured exercise (i.e., a sedentary lifestyle). Ageing and a sedentary lifestyle are associated with declines in muscle function and cardiorespiratory fitness, resulting in an impaired capacity to perform daily activities and maintain independent functioning. However, in the presence of adequate exercise/PA these changes in muscular and aerobic capacity with age are substantially attenuated. Additionally, both structured exercise and overall PA play important roles as preventive strategies for many chronic diseases, including cardiovascular disease, stroke, diabetes, osteoporosis, and obesity; improvement of mobility, mental health, and quality of life; and reduction in mortality, among other benefits. Notably, exercise intervention programmes improve the hallmarks of frailty (low body mass, strength, mobility, PA level, energy) and cognition, thus optimising functional capacity during ageing. In these pathological conditions exercise is used as a therapeutic agent and follows the precepts of identifying the cause of a disease and then using an agent in an evidence-based dose to eliminate or moderate the disease. Prescription of PA/structured exercise should therefore be based on the intended outcome (e.g., primary prevention, improvement in fitness or functional status or disease treatment), and individualised, adjusted and controlled like any other medical treatment. In addition, in line with other therapeutic agents, exercise shows a dose-response effect and can be individualised using different modalities, volumes and/or intensities as appropriate to the health state or medical condition. Importantly, exercise therapy is often directed at several physiological systems simultaneously, rather than targeted to a single outcome as is generally the case with pharmacological approaches to disease management. There are diseases for which exercise is an alternative to pharmacological treatment (such as depression), thus contributing to the goal of deprescribing of potentially inappropriate medications (PIMS). There are other conditions where no effective drug therapy is currently available (such as sarcopenia or dementia), where it may serve a primary role in prevention and treatment. Therefore, this consensus statement provides an evidence-based rationale for using exercise and PA for health promotion and disease prevention and treatment in older adults. Exercise prescription is discussed in terms of the specific modalities and doses that have been studied in randomised controlled trials for their effectiveness in attenuating physiological changes of ageing, disease prevention, and/or improvement of older adults with chronic disease and disability. Recommendations are proposed to bridge gaps in the current literature and to optimise the use of exercise/PA both as a preventative medicine and as a therapeutic agent.

A balance between meaningfulness and risk of harm - frail elderly patients' perceptions of physical activity and exercise - an interview study

Background

There is growing evidence of the benefits of physical activity and exercise for frail elderly patients with comorbidity. In order to improve participation in physical activity and exercise interventions, there is a need to increase our understanding of the patient’s perspective.

Aim

The aim of this study is to explore the perceptions of physical activity and exercise among frail elderly patients with a severe comorbidity burden.

Method

Face-to-face, in-depth interviews were conducted with eighteen frail elderly patients with a severe comorbidity burden, median age 85.5 years (min-max 75–94). The interviews were transcribed verbatim and analyzed according to content analysis inspired by Krippendorf.

Results

An overall theme, defined as “Meaningfulness and risk of harm in an aging body” was identified, followed by three main categories, labeled physical activity in daily life, goals of physical activity and exercise and prerequisites for physical activity and exercise, and eight sub-categories.

Conclusion

This study suggests that, in frail elderly patients with severe multimorbidity, physical activity and exercise is a balance between what is perceived as meaningful and the risk of harm. Patients perceived aging as an inevitable process that they needed to accept and gradually adapt their physical activities in daily life to match. As patients said they were unclear about the benefits and risks of exercise and referred to their previous life and experiences when describing physical activity and exercise, it is likely that the communication relating to this within the healthcare system needs to be further developed To promote physical activity and exercise to maintain or improve physical fitness in this frail population, healthcare providers need to use extended, personalized information to tailor the type of physical activities, goals and prerequisites for each patient.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-020-01868-2.

Short and Long-Term Trainability in Older Adults: Training and Detraining Following Two Years of Multicomponent Cognitive-Physical Exercise Training

Despite the benefits of multicomponent physical–cognitive training programs (MC^CogTPs), lower training intensities in the concurrent approach, and bigger heterogeneity with aging, suggest the need for long-term analyses, with special attention to training and detraining in older adults. The present study aims to examine these training/detraining effects in a two year MC^CogTP, looking for specific dynamics in the trainability of their physical and cognitive capacities. The intervention was divided into four periods: T1, T2 (8 months of training each), and D1, D2 (3.5 months of detraining plus 0.5 of testing each). Twenty-five healthy seniors (70.82 ± 5.18 years) comprised the final sample and were assessed for cardiovascular fitness (6-minutes walking test), lower-limbs strength (30-seconds chair-stand test) and agility (8-feet timed up-and-go test). Inhibition (Stroop test) was considered for executive function. Physical and cognitive status improved significantly (p < 0.05) throughout the two years, with larger enhancements for physical function (mainly strength and agility). Strength and cardiovascular fitness were more sensitive to detraining, whilst agility proved to have larger training retentions. Inhibition followed an initial similar trend, but it was the only variable to improve along D2 (d = 0.52), and changes were not significant within periods. Notwithstanding aging, and the exercise cessation in D2, physical and cognitive status remained enhanced two years later compared to baseline, except for lower-limb strength. According to these results, basic physical capacities are very sensitive to training/detraining, deserving continuous attention (especially strength). Both reducing detraining periods and complementary resistance training should be considered. Additionally, physical enhancements following MC^cogTPs may help cognition maintenance during detraining.

[Multicomponent physical exercise program: Vivifrail]

Introduction

Several studies have shown that exercise interventions reduce the incidence of falls in older adults with physical frailty. Older adults who participate in physical exercise (e.g., walking, strength training, or self-adjusted physical activity) are more likely to live with independence, remain healthy, and have reduced health-related costs. The effects of exercise prevent cardiovascular disease, decrease the risk of death, prevent diabetes, obesity and improved muscular function and quality of life. Multicomponent physical exercise programs are fundamental to maintaining mobility, musculoskeletal function and optimal function of other body systems: neurological, cardiovascular, respiratory, and endocrine. Multicomponent Vivifrail exercise program (www.vivifrail.com)with rapid screening for frailty and sarcopenia, tries to provide training on how to promote and prescribe physical exercise in older adults to maintain a level of function that provides the highest degree of autonomy possible.

Health Benefits of β-Hydroxy-β-Methylbutyrate (HMB) Supplementation in Addition to Physical Exercise in Older Adults: A Systematic Review with Meta-Analysis

Both regular exercise training and beta-hydroxy-beta-methylbutyrate (HMB) supplementation are shown as effective treatments to delay or reverse frailty and reduce cognitive impairment in older people. However, there is very little evidence on the true benefits of combining both strategies. The aim of this meta-analysis was to quantify the effects of exercise in addition to HMB supplementation, on physical and cognitive health in older adults. Data from 10 randomized controlled trials (RCTs) investigating the effect of HMB supplementation and physical function in adults aged 50 years or older were analyzed, involving 384 participants. Results showed that HMB supplementation in addition to physical exercise has no or fairly low impact in improving body composition, muscle strength, or physical performance in adults aged 50 to 80 years, compared to exercise alone. There is a gap of knowledge on the beneficial effects of HMB combined with exercise to preserve cognitive functions in aging and age-related neurodegenerative diseases. Future RCTs are needed to refine treatment choices combining HMB and exercises for older people in particular populations, ages, and health status. Specifically, interventions in older adults aged 80 years or older, with cognitive impairment, frailty, or limited mobility are required.

Factors associated with change in self-reported physical activity in the very old: The Newcastle 85+ study

BACKGROUND

Higher physical activity (PA) has been linked to better health and functioning. Trajectories of PA and associated factors have been studied in older adults aged ≥65, but less is known about influences on PA change in the very old (aged ≥85).

OBJECTIVE

To investigate factors associated with self-reported PA and PA change over time in very old adults.

METHODS

845 participants in the Newcastle 85+ Study were followed for health and functioning at 1.5-, 3-, and 5-year follow-up (wave 2 to 4). PA scores (range 0-18) and PA levels (low (PA scores 0-1), medium (2-6) and high (7-18)) were determined using a purpose-designed PA questionnaire. We used linear mixed models (LMM) to investigate factors associated with 5-year change in PA scores.

RESULTS

Overall, men had higher mean PA scores than women (up to 2.27 points). The highest proportion of participants (42-48%) had medium levels of PA across the waves. Although most experienced decline-stability in moderate and increases in high PA levels were also observed. The fully adjusted LMM revealed a curvilinear annual decline in PA scores of 0.52 (0.13) (β (SE), p<0.001), which decelerated by 0.07 (0.02) points (p<0.01) over time. The factors associated with low PA scores at baseline were female gender, higher waist-hip ratio, and no alcohol intake. Better self-rated and cognitive health and having fewer diseases were associated with higher PA scores. None were associated with the rate of change in PA over time.

CONCLUSION

We observed a curvilinear trend and deceleration in PA scores decline in the very old. Men and those in better health and who drank alcohol were more physically active at baseline. None of the factors were associated with the rate of PA decline. Investigating those who maintain or increase levels of PA may inform interventions for at risk groups with PA decline.

Effect of a multicomponent exercise programme (VIVIFRAIL) on functional capacity in frail community elders with cognitive decline: study protocol for a randomized multicentre control trial

BACKGROUND

The benefit of physical exercise in ageing and particularly in frailty has been the aim of recent research. Moreover, physical activity in the elderly is associated with a decreased risk of mortality, of common chronic illnesses (i.e. cardiovascular disease or osteoarthritis) and of institutionalization as well as with a delay in functional decline. Additionally, very recent research has shown that, despite its limitations, physical exercise is associated with a reduced risk of dementia, Alzheimer disease or mild cognitive decline. Nevertheless, the effect of physical exercise as a systematic, structured and repetitive type of physical activity, in the reduction of risk of cognitive decline in the elderly, is not very clear. The purpose of this study aims to examine whether an innovative multicomponent exercise programme called VIVIFRAIL has benefits for functional and cognitive status among pre-frail/frail patients with mild cognitive impairment or dementia.

METHODS/DESIGN

This study is a multicentre randomized clinical trial to be conducted in the outpatient geriatrics clinics of three tertiary hospitals in Spain. Altogether, 240 patients aged 75 years or older being capable of and willing to provide informed consent, with a Barthel Index ≥ 60 and mild cognitive impairment or mild dementia, pre-frail or frail and having someone to help to supervise them when conducting the exercises will be randomly assigned to the intervention or control group. Participants randomly assigned to the usual care group will receive normal outpatient care, including physical rehabilitation when needed. The VIVIFRAIL multicomponent exercise intervention programme consists of resistance training, gait re-training and balance training, which appear to be the best strategy for improving gait, balance and strength, as well as reducing the rate of falls in older individuals and consequently maintaining their functional capacity during ageing. The primary endpoint is the change in functional capacity, assessed with the Short Physical Performance Battery (1 point as clinically significant). Secondary endpoints are changes in cognitive and mood status, quality of life (EQ-5D), 6-m gait velocity and changes in gait parameters (i.e. gait velocity and gait variability) while performing a dual-task test (verbal and counting), handgrip, maximal strength and power of the lower limbs as well as Barthel Index of independence (5 points as clinically significant) at baseline and at the 1-month and 3-month follow-up.

DISCUSSION

Frailty and cognitive impairment are two very common geriatric syndromes in elderly patients and are frequently related and overlapped. Functional decline and disability are major adverse outcomes of these conditions. Exercise is a potential intervention for both syndromes. If our hypothesis is correct, the relevance of this project is that the results can contribute to understanding that an individualized multicomponent exercise programme (VIVIFRAIL) for frail elderly patients with cognitive impairment is more effective in reducing functional and cognitive impairment than conventional care. Moreover, our study may be able to show that an innovative individualized multicomponent exercise prescription for these high-risk populations is plausible, having at least similar therapeutic effects to other pharmacological and medical prescriptions.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03657940 . Registered on 5 September 2018.

Pre-Frail Multicomponent Training Intervention project for complexity of biological signals, functional capacity and cognition improvement in pre-frail older adults: A blinded randomized controlled study protocol

AIM

Frailty syndrome is related to decreased physiological complexity, functional capacity and cognition. Physical exercise has been suggested to slow down and reverse this syndrome. However, evidence of its effectiveness is not as straightforward as conventionally admitted, as there is a lack of trials with rigorous methodology. The purpose of this study was to describe the Pre-Frail Multicomponent Training Intervention protocol.

METHODS

Cardiovascular, motor control and neuromuscular systems of pre-frail older adults will be assessed by measuring the complexity of the output of these systems. Functional capacity and cognition will be assessed by specific tools. A 16-week training protocol will be carried out on three alternate days, with 60-min sessions, and combining aerobic, muscle strength, flexibility and balance exercises. The objective of this intervention is to improve the cardiovascular, motor control and neuromuscular systems, as well as functional capacity and cognition of pre-frail older adults. The assessment of these systems will be carried out using gold standard devices.

RESULTS

The results of the present study might allow clinical and functional support for the evaluation of the variables analyzed.

CONCLUSION

This protocol is easily reproducible and requires low-cost materials, thus the Pre-Frail Multicomponent Training Intervention could be a therapeutic strategy for pre-frail older adults. Geriatr Gerontol Int 2019; 19: 684-689.

The relationships and interactions between age, exercise and physiological function

This brief review focuses on the relationships and interactions between human ageing, exercise and physiological function. It explores the importance of the selection of participants for ageing research, the strengths and deficiencies of both cross-sectional and longitudinal studies, and the complexities involved in understanding time-dependent, lifelong physiological processes. As being physically active is crucial to fostering healthy ageing, it is essential that participants in health and ageing research are defined in terms of their physical activity/exercise status as well as other lifestyle factors. Comparisons of exercisers with non-exercisers has suggested that there is a mosaic of regulation of ageing both within and across physiological systems. We suggest that four broad categories exist which encompass this regulation. These are (i) systems and indices that are age dependent, but activity independent; (ii) systems that are age dependent, but also malleable by exercise; (iii) systems that are not age affected but are altered by exercise; and (iv) systems that are neither age nor activity dependent. We briefly explore the concept of a mosaic of regulation in a selection of physiological systems. These include skeletal muscle, the immune and endocrine systems, gastrointestinal as well as cognitive function. We go onto examine how these categories might fit within the broad framework of understanding the physiology of human ageing.

The Inherent Human Aging Process and the Facilitating Role of Exercise

Arguably the best available depictions of the global physiological changes produced by age are the profiles of world record performance times in swimming, athletics, and cycling, depicting the trajectory of decline in maximal integrated physiological performance capability. The curves suggest that the aging process produces a synchronized, controlled decrease in physiological performance over the human lifespan. The shape of the performance profile by age is essentially independent of discipline, distance, or phenotype. Importantly, the specific times of performance are not the driving force in the production of the shape of the declining performance profile. We suggest that in these highly trained individuals the shape of the curve is generated by the aging process operating on a physiology optimized for any given age. We hypothesize that with adequate training this same profile and trajectory, but with lower performance times, would be generated by all individuals who engage in sufficient physical activity/exercise. Unlike performance, data obtained from examining individual physiological systems or tissues do not give information on the unceasing and changing global integrating functions of the aging process. However, these data do give valuable information about the integrity of physiological systems at a particular age and allow a direct comparison to be made between the effects of inactivity and physical activity/exercise. Being physically active has been shown to have global protective effects on physiological systems and thus facilitates the aging process by maintaining physiological integrity. There is emerging evidence which suggests that physiological regulation of aging may be multi-compartmentalized. We do not advocate exercise as a panacea, but all the evidence indicates that being physically active and exercising is far superior to any other alternative for achieving optimal aging.

International Clinical Practice Guidelines for Sarcopenia (ICFSR): Screening, Diagnosis and Management

OBJECTIVES

Sarcopenia, defined as an age-associated loss of skeletal muscle function and muscle mass, occurs in approximately 6 - 22 % of older adults. This paper presents evidence-based clinical practice guidelines for screening, diagnosis and management of sarcopenia from the task force of the International Conference on Sarcopenia and Frailty Research (ICSFR).

METHODS

To develop the guidelines, we drew upon the best available evidence from two systematic reviews paired with consensus statements by international working groups on sarcopenia. Eight topics were selected for the recommendations: (i) defining sarcopenia; (ii) screening and diagnosis; (iii) physical activity prescription; (iv) protein supplementation; (v) vitamin D supplementation; (vi) anabolic hormone prescription; (vii) medications under development; and (viii) research. The ICSFR task force evaluated the evidence behind each topic including the quality of evidence, the benefit-harm balance of treatment, patient preferences/values, and cost-effectiveness. Recommendations were graded as either strong or conditional (weak) as per the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Consensus was achieved via one face-to-face workshop and a modified Delphi process.

RECOMMENDATIONS

We make a conditional recommendation for the use of an internationally accepted measurement tool for the diagnosis of sarcopenia including the EWGSOP and FNIH definitions, and advocate for rapid screening using gait speed or the SARC-F. To treat sarcopenia, we strongly recommend the prescription of resistance-based physical activity, and conditionally recommend protein supplementation/a protein-rich diet. No recommendation is given for Vitamin D supplementation or for anabolic hormone prescription. There is a lack of robust evidence to assess the strength of other treatment options.