Testosterone improves rehabilitation outcomes in ill older men

Testosterone replacement in men with sexual dysfunction

BACKGROUND

Clinical practice guidelines recommend testosterone replacement therapy (TRT) for men with sexual dysfunction and testosterone deficiency. However, TRT is commonly promoted in men without testosterone deficiency and existing trials often do not clearly report participants' testosterone levels or testosterone-related symptoms. This review assesses the potential benefits and harms of TRT in men presenting with complaints of sexual dysfunction.

OBJECTIVES

To assess the effects of testosterone replacement therapy compared to placebo or other medical treatments in men with sexual dysfunction.

SEARCH METHODS

We performed a comprehensive search of CENTRAL (the Cochrane Library), MEDLINE, EMBASE, and the trials registries ClinicalTrials.gov and World Health Organization International Clinical Trials Registry Platform, with no restrictions on language of publication or publication status, up to 29 August 2023.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) in men (40 years or over) with sexual dysfunction. We excluded men with primary or secondary hypogonadism. We compared testosterone or testosterone with phosphodiesterase-5 inhibitors (PDEI5I) to placebo or PDE5I alone.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the literature, assessed the risk of bias, extracted data, and rated the certainty of evidence (CoE) according to GRADE using a minimally contextualized approach. We performed statistical analyses using a random-effects model and interpreted them according to standard Cochrane methodology. Predefined primary outcomes were self-reported erectile dysfunction assessed by a validated instrument, sexual quality of life assessed by a validated instrument, and cardiovascular mortality. Secondary outcomes were treatment withdrawal due to adverse events, prostate-related events, and lower urinary tract symptoms (LUTS). We distinguished between short-term (up to 12 months) and long-term (> 12 months) outcomes.

MAIN RESULTS

We identified 43 studies with 11,419 randomized participants across three comparisons: testosterone versus placebo, testosterone versus PDE5I, and testosterone with PDE5I versus PDE5I alone. This abstract focuses on the most relevant comparison of testosterone versus placebo. Testosterone versus placebo (up to 12 months) Based on a predefined sensitivity analysis of studies at low risk of bias, and an analysis combing data from the similar International Index of Erectile Function (IIEF-EF) and IIEF-5 instruments, TRT likely results in little to no difference in erectile function assessed with the IIEF-EF (mean difference (MD) 2.37, 95% confidence interval (CI) 1.67 to 3.08; I² = 0%; 6 RCTs, 2016 participants; moderate CoE) on a scale from 6 to 30 with larger values reflecting better erectile function. We assumed a minimal clinically important difference (MCID) of greater than or equal to 4. TRT likely results in little to no change in sexual quality of life assessed with the Aging Males' Symptoms scale (MD -2.31, 95% CI -3.63 to -1.00; I² = 0%; 5 RCTs, 1030 participants; moderate CoE) on a scale from 17 to 85 with larger values reflecting worse sexual quality of life. We assumed a MCID of greater than or equal to 10. TRT also likely results in little to no difference in cardiovascular mortality (risk ratio (RR) 0.83, 95% CI 0.21 to 3.26; I² = 0%; 10 RCTs, 3525 participants; moderate CoE). Based on two cardiovascular deaths in the placebo group and an assumed MCID of 3%, this would correspond to no additional deaths per 1000 men (95% CI 1 fewer to 4 more). TRT also likely results in little to no difference in treatment withdrawal due to adverse events, prostate-related events, or LUTS. Testosterone versus placebo (later than 12 months) We are very uncertain about the longer-term effects of TRT on erectile dysfunction assessed with the IIEF-EF (MD 4.20, 95% CI -2.03 to 10.43; 1 study, 42 participants; very low CoE). We did not find studies reporting on sexual quality of life or cardiovascular mortality. We are very uncertain about the effect of testosterone on treatment withdrawal due to adverse events. We found no studies reporting on prostate-related events or LUTS.

AUTHORS' CONCLUSIONS

In the short term, TRT probably has little to no effect on erectile function, sexual quality of life, or cardiovascular mortality compared to a placebo. It likely results in little to no difference in treatment withdrawals due to adverse events, prostate-related events, or LUTS. In the long term, we are very uncertain about the effects of TRT on erectile function when compared to placebo; we did not find data on its effects on sexual quality of life or cardiovascular mortality. The certainty of evidence ranged from moderate (signaling that we are confident that the reported effect size is likely to be close to the true effect) to very low (indicating that the true effect is likely to be substantially different). The findings of this review should help to inform future guidelines and clinical decision-making at the point of care.

Current Nutritional and Pharmacological Approaches for Attenuating Sarcopenia

Sarcopenia is characterized by a gradual slowing of movement due to loss of muscle mass and quality, decreased power and strength, increased risk of injury from falls, and often weakness. This review will focus on recent research trends in nutritional and pharmacological approaches to controlling sarcopenia. Because nutritional studies in humans are fairly limited, this paper includes many results from nutritional studies in mammals. The combination of resistance training with supplements containing amino acids is the gold standard for preventing sarcopenia. Amino acid (HMB) supplementation alone has no significant effect on muscle strength or muscle mass in sarcopenia, but the combination of HMB and exercise (whole body vibration stimulation) is likely to be effective. Tea catechins, soy isoflavones, and ursolic acid are interesting candidates for reducing sarcopenia, but both more detailed basic research on this treatment and clinical studies in humans are needed. Vitamin D supplementation has been shown not to improve sarcopenia in elderly individuals who are not vitamin D-deficient. Myostatin inhibitory drugs have been tried in many neuromuscular diseases, but increases in muscle mass and strength are less likely to be expected. Validation of myostatin inhibitory antibodies in patients with sarcopenia has been positive, but excessive expectations are not warranted.

Sarcopenia in Immune-Mediated Rheumatic Diseases-Review

INTRODUCTION

Sarcopenia is a condition characterized by decreased muscle strength and muscle mass, which can impact physical function. Sarcopenia develops as a consequence of age-related decline (primary sarcopenia) and has a major impact on physical, social, and emotional well-being. In addition, patients with rheumatic diseases may suffer from sarcopenia independently of aging (secondary sarcopenia). Exercise, pharmacological treatments, and nutritional supplementation are some of the strategies used for the management of sarcopenia in the general population. The aim of this review is to summarize the evidence around the prevalence and impact of sarcopenia in patients with rheumatic diseases.

CONCLUSIONS

From our review, we can state that sarcopenia is a common and prevalent condition among the rheumatic diseases. Furthermore, the impacts of sarcopenia are not well-appreciated, and the implementation of treatment strategies has not been widespread. Strategies such as exercise and some pharmacological treatments are effective in improving physical and functional impairment related to these conditions.

FUTURE RESEARCH DIRECTIONS IN THE FIELD

New pharmacological treatments are being actively studied and may contribute in the future to the management of sarcopenia.

Novel Insights into the Pathogenesis of Spinal Sarcopenia and Related Therapeutic Approaches: A Narrative Review

Spinal sarcopenia is a complex and multifactorial disorder associated with a loss of strength, increased frailty, and increased risks of fractures and falls. In addition, spinal sarcopenia has been associated with lumbar spine disorders and osteoporosis, which renders making decisions on treatment modalities difficult. Patients with spinal sarcopenia typically exhibit lower cumulative survival, a higher risk of in-hospital complications, prolonged hospital stays, higher postoperative costs, and higher rates of blood transfusion after thoracolumbar spine surgery. Several studies have focused on the relationships between spinal sarcopenia, appendicular muscle mass, and bone-related problems-such as osteoporotic fractures and low bone mineral density-and malnutrition and vitamin D deficiency. Although several techniques are available for measuring sarcopenia, each of them has its advantages and shortcomings. For treating spinal sarcopenia, nutrition, physical therapy, and medication have been proven to be effective; regenerative therapeutic options seem to be promising owing to their repair and regeneration potential. Therefore, in this narrative review, we summarize the characteristics, detection methodologies, and treatment options for spinal sarcopenia, as well as its role in spinal disorders.

Body composition and sarcopenia: The next-generation of personalized oncology and pharmacology?

Body composition has gained increasing attention in oncology in recent years due to fact that sarcopenia has been revealed to be a strong prognostic indicator for survival across multiple stages and cancer types and a predictive factor for toxicity and surgery complications. Accumulating evidence over the last decade has unraveled the "pharmacology" of sarcopenia. Lean body mass may be more relevant to define drug dosing than the "classical" body surface area or flat-fixed dosing in patients with cancer. Since sarcopenia has a major impact on patient survival and quality of life, therapeutic interventions aiming at reducing muscle loss have been developed and are being prospectively evaluated in randomized controlled trials. It is now acknowledged that this supportive care dimension of oncological management is essential to ensure the success of any anticancer treatment. The field of sarcopenia and body composition in cancer is developing quickly, with (i) the newly identified concept of sarcopenic obesity defined as a specific pathophysiological entity, (ii) unsolved issues regarding the best evaluation modalities and cut-off for definition of sarcopenia on imaging, (iii) first results from clinical trials evaluating physical activity, and (iv) emerging body-composition-tailored drug administration schemes. In this context, we propose a comprehensive review providing a panoramic approach of the clinical, pharmacological and therapeutic implications of sarcopenia and body composition in oncology.

Testosterone Replacement, Muscle Strength, and Physical Function

Muscle strength and physical function decrease in older men, as do testosterone levels. Nonetheless, the effects of testosterone replacement therapy on muscle strength and physical function remain inconclusive and equivocal. We conducted a rapid systematic review, the results of which showed that testosterone replacement does not affect muscle strength (measured by hand grip strength and leg muscle strength), although it may increase physical function (measured by the 6-minute walk test, Physical Activity Scale for the Elderly score, and other physical performance tests). However, most of the studies were conducted in the United States or Europe and did not include participants from Asian or other ethnic backgrounds; therefore, further studies are needed to evaluate the effects of testosterone replacement in a broader population.

Drugs of Muscle Wasting and Their Therapeutic Targets

Muscle wasting and weakness such as cachexia, atrophy, and sarcopenia are characterized by marked decreases in the protein content, myonuclear number, muscle fiber size, and muscle strength. This chapter focuses on the recent advances of pharmacological approach for attenuating muscle wasting.A myostatin-inhibiting approach is very intriguing to prevent sarcopenia but not muscular dystrophy in humans. Supplementation with ghrelin is also an important candidate to combat sarcopenia as well as cachexia. Treatment with soy isoflavone, trichostatin A (TSA), and cyclooxygenase 2 (Cox2) inhibitors seems to be effective modulators attenuating muscle wasting, although further systematic research is needed on this treatment in particular concerning side effects.

Guidelines for the Use of Orexigenic Drugs in Long-Term Care

Undernutrition is defined as a state induced by nutrient deficiency that may be improved solely by administration of nutrients. By this definition, provision of adequate protein and energy sources should reverse the clinical presentation and correct the problem. However, a large number of patients who seem to be undernourished fail to respond to refeeding. A developing understanding of the acute-phase inflammatory response to illness and the role of cytokines in the pathophysiology of chronic illness has challenged the current diagnostic paradigm of undernutrition. In the presence of adequate food, weight loss is most often due to cytokine-associated cachexia and anorexia. Failure of appetite, or anorexia, may play a role in involuntary weight loss. Intervention for involuntary weight loss should aim first at the provision of adequate calories and protein, often in the form of high-density nutrition supplements. However, cytokine-mediated cachexia is remarkably resistant to hypercaloric feeding. With continued weight loss, the use of an orexigenic drug should be considered. Orexigenic drugs have been demonstrated to improve appetite and produce weight gain. The mechanism is unknown but may relate to suppression of proinflammatory cytokines. General guidelines for the use of orexigenic agents are presented. Although much work remains to be done, anticytokine drugs seem to be a promising avenue for the treatment of involuntary weight loss.

Treatment of Men for “Low Testosterone”: A Systematic Review

Testosterone products are recommended by some prescribers in response to a diagnosis or presumption of “low testosterone” (low-T) for cardiovascular health, sexual function, muscle weakness or wasting, mood and behavior, and cognition. We performed a systematic review of 156 eligible randomized controlled trials in which testosterone was compared to placebo for one or more of these conditions. We included studies in bibliographic databases between January 1, 1950 and April 9, 2016, and excluded studies involving bodybuilding, contraceptive effectiveness, or treatment of any condition in women or children. Studies with multiple relevant endpoints were included in all relevant tables. Testosterone supplementation did not show consistent benefit for cardiovascular risk, sexual function, mood and behavior, or cognition. Studies that examined clinical cardiovascular endpoints have not favored testosterone therapy over placebo. Testosterone is ineffective in treating erectile dysfunction and controlled trials did not show a consistent effect on libido. Testosterone supplementation consistently increased muscle strength but did not have beneficial effects on physical function. Most studies on mood-related endpoints found no beneficial effect of testosterone treatment on personality, psychological well-being, or mood. The prescription of testosterone supplementation for low-T for cardiovascular health, sexual function, physical function, mood, or cognitive function is without support from randomized clinical trials.

Androgen Therapy and Rehospitalization in Older Men With Testosterone Deficiency

OBJECTIVE

To assess whether the receipt of androgen therapy is associated with a reduced 30-day rehospitalization rate among older men with testosterone deficiency.

PATIENTS AND METHODS

We conducted a retrospective cohort study using a 5% national sample of Medicare beneficiaries. We identified 6372 nonsurgical hospitalizations between January 1, 2007, and December 31, 2012, for male patients aged 66 years and older with a previous diagnosis of testosterone deficiency. Patients who died or lost Medicare coverage in the 30 days after hospital discharge or who were discharged to another inpatient setting were excluded from the analysis. Logistic regression was used to calculate odds ratios (ORs) and 95% CIs for the risk of 30-day hospital readmissions associated with receipt of androgen therapy.

RESULTS

In older men with testosterone deficiency, receipt of androgen therapy was associated with a reduced risk of rehospitalization (91 of 929 androgen users [9.8%] vs 708 of 5443 non-androgen users [13.0%]; OR, 0.73; 95% CI, 0.58-0.92) in the 30 days after hospital discharge. In a logistic regression analysis adjusting for multiple demographic, clinical, and health service variables, the OR was similar (OR, 0.75; 95% CI, 0.59-0.95). The adjusted OR for unplanned 30-day hospital readmissions was 0.62 (95% CI, 0.47-0.83). Each of these findings persisted across a range of propensity score analyses-including adjustment, stratification, and inverse probability treatment weighting-and several sensitivity analyses.

CONCLUSION

Androgen therapy may reduce the risk of rehospitalization in older men with testosterone deficiency. Given the high rates of early hospital readmission among older adults, further exploration of this intervention holds broad clinical and public health relevance.

The Randomized Control Trial of the Effects of Testosterone and a Nutritional Supplement On Hospital Admissions in Undernourished, Community Dwelling, Older People

OBJECTIVE

In a pilot single centre study we found that treatment of undernourished older, community dwelling people for one year with oral testosterone (placebo-controlled) and a nutritional supplement (no control) was associated with a significant reduction in hospitalizations. A larger, multicentre study was conducted to investigate further this potentially important finding.

DESIGN

One year, randomized, placebo-controlled, multi-centre, double-blind, trial.

SETTING

Community.

PARTICIPANTS

53 undernourished men and women aged 65 years and older.

INTERVENTION

Oral testosterone undecanoate (40 mg/day women, 160 mg/day men) and high energy oral nutritional supplement (2108-2416 kJ/day) or placebo medication and low energy (142-191 kJ/day) "placebo" oral nutritional supplementation.

MEASUREMENTS

Hospital admissions, falls and other variables were assessed.

RESULTS

53 subjects were recruited (64% male and mean age 77 years), which was substantially less than planned. Sixteen subjects (30%) were admitted to hospital at least once, with a total of 29 admissions. Eight subjects (32%) in the placebo arm were admitted to hospital, whilst in the intervention group also there were eight (29%) subjects admitted to hospital during the study period. There was no difference in the number of hospitalisations (P = 0.842), length of hospitalization (P=0.645) or quality of life [mental health P=0.195 and physical health P=0.451) between the treatment arms.

CONCLUSIONS

In undernourished older people, treatment with testosterone and a nutritional supplementation did not reduce the number and length of hospitalisations or improve quality of life.

Optimizing the benefits of exercise on physical function in older adults

As the number of older adults continues to rise worldwide, the prevention of physical disability among seniors is an increasingly important public health priority. Physical exercise is among the best known methods of preventing disability, but accumulating evidence indicates that considerable variability exists in the responsiveness of older adults to standard training regimens. Accordingly, a need exists to develop tailored interventions to optimize the beneficial effects of exercise on the physical function of older adults at risk for becoming disabled. The present review summarizes the available literature related to the use of adjuvant or alternative strategies intended to enhance the efficacy of exercise in improving the physical function of older adults. Within this work, we also discuss potential future research directions in this area.

A UK epidemic of testosterone prescribing, 2001-2010

CONTEXT

Testosterone replacement therapy is the standard treatment for male hypogonadism. There has lately been increased marketing in the medical media promoting testosterone replacement for men with erectile dysfunction or for older men with low serum testosterone, despite the lack of long-term safety and efficacy data. Therefore, we aimed to examine trends in testosterone prescribing in UK primary care over the last 10 years.

METHODS

Data about the use of testosterone preparations from the Departments of Health Prescription Cost Analysis for community pharmacies 2001-2010, for England, Scotland and Wales, were collated. Community requests for serum total testosterone assay in men to the Biochemistry Department at the Newcastle upon Tyne Hospitals Trust were also examined over the same time period.

RESULTS

The number of prescriptions for testosterone preparations increased by nearly 90% from 157 602 to 298 134 dispensed items annually, over a 10-year period. However, due to a particularly significant (fivefold) increase in prescribing of (more expensive) transdermal preparations, the cost to the NHS showed a 267% escalation, from £3·2 to £11·7 million, annually over the same period. Local requests from primary care in the Newcastle and North Tyneside area for serum testosterone measurement in men also increased, from 347 requests in 2000 to 823 requests in 2010, a 137% increase. However, the number of men with likely unequivocal hypogonadism (testosterone less than 6·0 nm) remained constant at 5·2% in 2000 and 6·3% in 2010.

CONCLUSION

Many men in the UK might be receiving testosterone replacement therapy with neither clearly established indications nor robustly diagnosed hypogonadism. A national registry for men treated with testosterone and further evidence to improve current guidance (national and/or international) on the indications for testosterone replacement would be beneficial.

Sarcopenia and cachexia: the adaptations of negative regulators of skeletal muscle mass

Recent advances in our understanding of the biology of muscle, and how anabolic and catabolic stimuli interact to control muscle mass and function, have led to new interest in the pharmacological treatment of muscle wasting. Loss of muscle occurs as a consequence of several chronic diseases (cachexia) as well as normal aging (sarcopenia). Although many negative regulators [Atrogin-1, muscle ring finger-1, nuclear factor-kappaB (NF-κB), myostatin, etc.] have been proposed to enhance protein degradation during both sarcopenia and cachexia, the adaptation of mediators markedly differs among these conditions. Sarcopenic and cachectic muscles have been demonstrated to be abundant in myostatin- and apoptosis-linked molecules. The ubiquitin-proteasome system (UPS) is activated during many different types of cachexia (cancer cachexia, cardiac heart failure, chronic obstructive pulmonary disease), but not many mediators of the UPS change during sarcopenia. NF-κB signaling is activated in cachectic, but not in sarcopenic, muscle. Some studies have indicated a change of autophagic signaling during both sarcopenia and cachexia, but the adaptation remains to be elucidated. This review provides an overview of the adaptive changes in negative regulators of muscle mass in both sarcopenia and cachexia.

Sarcopenia and age-related endocrine function

Sarcopenia, the age-related loss of skeletal muscle, is characterized by a deterioration of muscle quantity and quality leading to a gradual slowing of movement, a decline in strength and power, and an increased risk of fall-related injuries. Since sarcopenia is largely attributed to various molecular mediators affecting fiber size, mitochondrial homeostasis, and apoptosis, numerous targets exist for drug discovery. In this paper, we summarize the current understanding of the endocrine contribution to sarcopenia and provide an update on hormonal intervention to try to improve endocrine defects. Myostatin inhibition seems to be the most interesting strategy for attenuating sarcopenia other than resistance training with amino acid supplementation. Testosterone supplementation in large amounts and at low frequency improves muscle defects with aging but has several side effects. Although IGF-I is a potent regulator of muscle mass, its therapeutic use has not had a positive effect probably due to local IGF-I resistance. Treatment with ghrelin may ameliorate the muscle atrophy elicited by age-dependent decreases in growth hormone. Ghrelin is an interesting candidate because it is orally active, avoiding the need for injections. A more comprehensive knowledge of vitamin-D-related mechanisms is needed to utilize this nutrient to prevent sarcopenia.

The effect of testosterone and a nutritional supplement on hospital admissions in under-nourished, older people

Background

Weight loss and under-nutrition are relatively common in older people, and are associated with poor outcomes including increased rates of hospital admissions and death. In a pilot study of 49 undernourished older, community dwelling people we found that daily treatment for one year with a combination of testosterone tablets and a nutritional supplement produced a significant reduction in hospitalizations. We propose a larger, multicentre study to explore and hopefully confirm this exciting, potentially important finding (NHMRC project grant number 627178).

Methods/Design

One year randomized control trial where subjects are allocated to either oral testosterone undecanoate and high calorie oral nutritional supplement or placebo medication and low calorie oral nutritional supplementation. 200 older community-dwelling, undernourished people [Mini Nutritional Assessment score <24 and either: a) low body weight (body mass index, in kg/m²: <22) or b) recent weight loss (>7.5% over 3 months)]. Hospital admissions, quality-adjusted life years, functional status, nutritional health, muscle strength, body composition and other variables will be assessed.

Discussion

The pilot study showed that combined treatment with an oral testosterone and a supplement drink was well tolerated and safe, and reduced the number of people hospitalised and duration of hospital admissions in undernourished, community dwelling older people. This is an exciting finding, as it identifies a treatment which may be of substantial benefit to many older people in our community. We now propose to conduct a multi-centre study to test these findings in a substantially larger subject group, and to determine the cost effectiveness of this treatment.

Trial registration

Australian Clinical Trial Registry: ACTRN 12610000356066

Change in thigh muscle cross-sectional area through administration of an anabolic steroid during routine stroke rehabilitation in hemiplegic patients

OBJECTIVE

The aim of this study was to clarify the effect of administration of an anabolic steroid (AS) without the addition of specific training in stroke patients by measuring the cross-sectional area (CSA) of the thigh.

DESIGN

Twenty-six hemiplegic stroke patients during subacute rehabilitation were randomly assigned to a metenolone enanthate (ME) administration group or a control group (CT group). In the ME group, ME (100 mg) was injected intramuscularly weekly for 6 wks in the ME group. The CSA of the bilateral thigh muscles was measured using computed tomography. Motor subscore of the Functional Independence Measure (FIM-M) was assessed before the experimental period.

RESULTS

At the end of 6 wks, the CSA increase in the ME group (13.4%, affected side; 14.5%, unaffected side) was significantly larger than that in the CT group (3.3%, affected side; 5.2%, unaffected side). Correlation coefficients between the initial FIM-M score and the CSA increase at 6 wks were -0.754 for the affected side and -0.567 for the unaffected side in the ME group and 0.199 for the affected side and 0.431 for the unaffected side in the CT group.

CONCLUSIONS

ME administration is effective for improving muscle CSA and, thus, muscle strengthening in stroke rehabilitation. The CSA increase in the ME group was most prominent in patients with a low initial FIM-M score.

Effect of standing posture during whole body vibration training on muscle morphology and function in older adults: a randomised controlled trial

BACKGROUND

Whole body vibration (WBV) is a novel modality of exercise shown to improve musculoskeletal function. This study aims to examine the effects of standing posture during low magnitude WBV training on muscle function and muscle morphology in older adults.

METHODS

Nineteen men and women (50-80 years) were recruited to a three month randomised controlled trial and allocated to one of three groups: WBV with flexed knees (FK), WBV with locked knees (LK), or sham WBV with flexed knees (CON). Exposure was intermittent (1 min WBV:1 min rest) for 20 min, three times per week for 13 weeks. Measurements were taken at baseline and at three months. Primary outcomes included upper and lower body muscle function (strength, power and velocity). Secondary outcomes were muscle morphology, balance, habitual and maximal gait velocity, stair climb power, and chair stand performance.

RESULTS

Sixteen subjects completed the study. Relative (%) upper body contraction velocity improved significantly after WBV with FK compared to LK (FK 16.0%, LK -7.6%, CON 4.7, p = 0.01). Relative upper body strength (LK 15.1%, p = 0.02; FK 12.1%, p = 0.04; CON 4.7%) increased significantly following WBV compared to control. Absolute (p = 0.05) and relative (p = 0.03) lower leg strength significantly improved with both standing postures (LK 14.4%; FK 10.7%; CON 1.3%). Only the LK group differed significantly from CON in relative leg strength gains (p = 0.02). Potentially clinically meaningful but statistically non-significant improvements in lower leg muscle cross-sectional area (LK 3.7 cm², FK 2.4 cm², CON 2.2 cm² p = 0.13) were observed after WBV with LK compared to the other groups. No significant effects of WBV on any functional performance tests were observed.

CONCLUSIONS

Our results suggest that WBV may improve muscle strength and contraction velocity in some muscle groups in older adults. However, hypothesised differential adaptation to standing posture (FK > LK) was observed only for upper body contraction velocity, making recommendations regarding this prescriptive element inconclusive. The efficacy, mechanism of action and long term feasibility of WBV for musculoskeletal health in older adults warrants continued investigation in robustly designed, sufficiently powered future studies.

TRIAL REGISTRATION

ACTRN12609000353291.

Skeletal muscle wasting in cachexia and sarcopenia: molecular pathophysiology and impact of exercise training

Skeletal muscle is the most abundant tissue in the human body, and the maintenance of its mass is essential to ensure basic function as locomotion, strength and respiration. The decision to synthesize or to break down skeletal muscle proteins is regulated by a network of signaling pathways that transmit external stimuli to intracellular factors regulating gene transcription. The tightly regulated balance of muscle protein breakdown and synthesis is disturbed in several distinct myopathies, but also in two pathologies: sarcopenia and cachexia. In recent years, it became evident that in these two muscle wasting disorders specific regulating molecules are increased in expression (e.g. members of the ubiquitin-proteasome system, myostatin, apoptosis inducing factors), whereas other factors (e.g. insulin-like growth factor 1) are down-regulated. So far, not many treatment options to fight the muscle loss are available. One of the most promising approaches is exercise training that, due to its multifactorial effects, can act on several signaling pathways. Therefore, this review will concentrate on specific alterations discussed in the current literature that are present in the skeletal muscle of both muscle wasting disorders. In addition, we will focus on exercise training as an intervention strategy.

Aging Men and Lipids

Many theories aim at explaining the mechanisms of aging and death in humans. Decreased levels of androgens, growth hormone, and insulin-like growth factor accompany natural aging in men. Androgens influence the growth and maturation of men in various stages of their life. The action of androgens is performed by binding or not binding to androgen receptors. However, various actions of androgens were clarified after the discovery and genotyping of the androgen receptor. The influence of androgens on the lipid profile was reported by several researchers. This negative influence of androgens in men and the positive influence of estrogens in women are responsible for the higher impact of atherogenesis in men compared with women. In aging men, this negative influence of androgens on the lipid profile is more pronounced. This review considers the influence of age on lipid metabolism in men.

The effect of whole body vibration exposure on muscle or bone morphology and function in older adults: a systematic review of the literature

CONTEXT AND OBJECTIVE

The aim of this study was to examine the effect of whole body vibration (WBV), a novel exercise modality, on muscle or bone morphology and function in older adults.

METHODS

A literature search of published randomised controlled trials (RCTs) was conducted using multiple databases and hand searching for study designs reporting the effects of WBV in older adults on any outcomes related to muscle function, or muscle or bone morphology. Concomitant exercise was only included if the control group performed the same exercise as the active WBV group, but without vibration.

RESULTS

Six RCTs met the inclusion criteria of this review, three reporting measures of muscle only, two assessing bone measures only and one detailing measures of both bone and muscle. Study design varied greatly across the six trials and only six of 35 musculoskeletal outcomes analysed were statistically significant. All statistically significant improvements were of muscle function.

CONCLUSIONS

The published literature to date provides only weak support for the efficacy of WBV exposure for muscle function, muscle morphology, or bone architecture in older adults. Irregularities in study design and WBV protocols across the literature and poor quality trials contribute to this inconsistency, revealing the need for more uniformity in future trials. Future research should be more robust in design, include larger cohorts, longer interventions and standardisation of protocols. They should also investigate the optimal dose-response relationships and variation in vibration characteristics, to determine the true efficacy, clinical relevance, and underlying mechanisms of muscle and bone adaptations.

Is there a neuroendocrinological rationale for testosterone as a therapeutic option in depression?

Depression is a disease of growing incidence and economic burden worldwide. In view of increasing treatment resistance, new therapeutic approaches are urgently needed. In addition to its gonadal functions, testosterone has many effects on the central nervous system. An association between testosterone levels and depressive symptoms has been proposed. Many hormones and neurotransmitters are involved in the aetiology and the course of depression including serotonin, dopamine, noradrenaline, vasopressin and cortisol. Testosterone is known to interact with them. Preclinical data suggest that testosterone has antidepressant potential. However, the data from clinical studies have been inconsistent. This review provides a critical overview on the currently available preclinical and clinical literature and concludes with clinical recommendations.

Undernutrition and anorexia in the older person

Minimizing frailty in older age is important to individuals and society, as the increasing prevalence of chronic disease is leading to greater disability and health care costs. Nutritional frailty can be defined as the disability that occurs in old age due to rapid, unintentional loss of body weight and sarcopenia (lack of lean mass). This article provides a brief overview of the prevalence and consequences of undernutrition, age-related changes to appetite, food intake, and body composition, the factors contributing to the development of anorexia and undernutrition, and recommended management strategies.

Effect of testosterone and a nutritional supplement, alone and in combination, on hospital admissions in undernourished older men and women

BACKGROUND

In older people, undernutrition is associated with increased hospitalization rates and mortality. Because weight loss in older people often reflects a disproportionate reduction of skeletal muscle, anabolic treatments may be beneficial.

OBJECTIVE

Our aim was to evaluate the hypothesis that testosterone treatment and a nutritional supplement have additive benefits.

DESIGN

Oral testosterone undecanoate (40 mg daily for women, 80 mg twice daily for men) and an oral nutritional supplement (475 kcal/d) were administered, alone or combined, for 1 y to 49 community-dwelling, undernourished people [Mini Nutritional Assessment score <24 and low body weight (body mass index, in kg/m(2): <22) or recent weight loss (>7.5% over 3 mo)] aged >65 y (mean age: 77 y; 26 women and 23 men). Hospital admissions and other variables were assessed.

RESULTS

In subjects receiving combined testosterone and nutritional supplements (n = 11), there were no hospital admissions, whereas there were 9 admissions (2 elective) in 13 subjects in the no-treatment group, 4 in the testosterone-treated group (n = 12), and 5 in the supplement-treated group (n = 13); P = 0.06 with no-treatment compared with combined treatment. When compared with the no-treatment group, the combined-treatment group had significantly fewer subjects admitted to hospital (0 compared with 5, P = 0.03), fewer days in hospital (0 compared with 74, P = 0.041), and a longer time to hospital admission (P = 0.017).

CONCLUSIONS

In undernourished older people, combined treatment with testosterone and nutritional supplementation reduced the number of people hospitalized and the duration of hospital admissions, which are important endpoints in this group. Larger, confirmatory studies are now needed. This trial was registered before commencement at clinical trials.gov as NCT00117000.

Testosterone treatment in elderly men

Testosterone has been used in testicular and hypothalamo-pituitary diseases since the 1940s. There is growing interest in the use of testosterone in aging men, and this has stimulated research into the benefits of male hormone replacement. Testosterone treatment of men with hypogonadism might have beneficial effects on body composition, muscle strength, sexual function, and cognition. There are several modes of administration of the male hormone, with injectable testosterone esters and implanted testosterone pellets being the mainstay of treatment until recently. These preparations are increasingly being replaced by transdermal patches, gels, and long-acting parenteral preparations. Testosterone patches and gels are ideally for elderly men. Treatment with the male hormone is relatively safe, if patients are selected appropriately and monitored carefully. The most important adverse effects are on the prostate. In this review, we briefly discuss the indications, contraindications, and benefits of testosterone treatment. Further, we list the adverse effects, advantages, and disadvantages of various testosterone preparations in elderly men.

Anabolic-androgenic steroid effects on early morbid symptoms after open prostatectomy: a pilot study

OBJECTIVES

Anabolic-androgenic steroids such as Nandrolone phenpropionate (NP) dramatically improve the tolerance to acute stress conditions, strength, and subsequently the quality of life in elderly men. We hypothesize that preoperative pulse-dose supraphysiological NP administration might improve the early morbid symptoms in older patients undergoing open prostatectomy.

METHODS

From 2005 to 2006, 54 patients with a mean age of 70 years, diagnosed as benign prostatic hyperplasia and hospitalized for open prostatectomy were enrolled in the study. They were randomly selected to receive preoperative supraphysiological NP (100 mg, intramuscularly, pulse-dose) or sesame oil placebo, prospectively. Early postoperative morbid symptoms including subjective urinary symptoms (dysuria, bladder retention sensation), incision site pain and general satisfaction of their current urinary condition were assessed by a 6-point scale, self-administrated questionnaire at 24 and 48 h, postoperatively. The sex hormone binding globulin and the testosterone levels were also measured.

RESULTS

The 24-h postoperative symptoms were significantly reduced in the NP group compared to the placebo (6.18 +/- 2.81 versus 9.77 +/- 2.15; P < 0.001). The postoperative symptoms were reported to have a decline in the 48 h following operation, though was calculated to be statistically insignificant (4.48 +/- 2.32 versus 5.55 +/- 1.84; P = 0.06). There was no complication attributed to NP therapy.

CONCLUSIONS

The data supported the hypothesis that the preoperative anabolic steroid supplements (such as NP) could result in a better postoperative endurance in elderly men undergoing open prostatectomy. Further studies, longer and repeated pulse injections in a larger number of older men are mandatory to prove the claim.

Unintended weight loss in older persons

Unintended weight loss has a profound effect on morbidity and mortality in older persons. A therapeutic approach to unintended weight loss in older persons depends on correct classification. A careful differential diagnostic approach is mandatory, combined with nutritional and often pharmacological interventions. While starvation due to protein-energy undernutrition is widely regarded as the primary cause of loss of fat and fat-free mass in older persons, a failure to improve with nutritional replacement should trigger a consideration of other causes. Both sarcopenia and cachexia are resistant to hypercaloric feeding. Cachexia may be amenable to suppression of proinflammatory cytokines in known inflammatory disease states.

Sex Hormone Levels and Functional Outcomes

OBJECTIVES

To investigate testosterone and free testosterone levels in male patients after spinal cord injury (SCI) in comparison with healthy subjects, the effects of free testosterone on Functional Independence Measure (FIM) instrument, and their relationship between time since injury, spinal cord injury levels, and testosterone levels.

DESIGN

Prospective case series during 2004-2005. Male patients with SCI (n = 44) and a control group (n = 42) from healthy volunteers with similar age and body mass index were included in the study. Plasma luteinizing hormone (LH) was measured along with testosterone and free testosterone in the same blood sample. The FIM instrument was administered at the admission to hospital and at discharge.

RESULTS

Serum LH levels were significantly higher in both patient subgroups than in the control group (P < 0.01 and 0.03). Free testosterone levels were lower in the subgroup with time since injury <or=12 mos than in the other patient subgroup and the control group (P = 0.01 and 0.02). No significance was found between androgen status and FIM change.

CONCLUSIONS

Our findings suggest that a negative androgen status might be notable especially in the first year after spinal cord injury. However, the androgen status does not correlate with functional outcome in patients coming for rehabilitation after spinal cord injury.

Testosterone Levels Among Men with Spinal Cord Injury Admitted to Inpatient Rehabilitation

OBJECTIVE

Although previous research has shown an association between spinal cord injury (SCI) and testosterone production, these studies have yielded inconsistent results. The present study documented the prevalence of low testosterone among men with SCI.

DESIGN

Participants were 92 men with SCI participating in inpatient rehabilitation. Data included total serum testosterone level, demographic and injury information, neurologic level and degree of incomplete function, American Spinal Injury Association Impairment Scale grade, and additional laboratory values, including prealbumin, albumin, hematocrit, and aspartate aminotransferase.

RESULTS

The median testosterone level for men who sustained injuries <4 mos earlier was 160 ng/dl. Testosterone categories were significantly associated with age, time since injury, hematocrit, albumin level, and aspartate aminotransferase in the univariate analyses. Age, time since injury, and hematocrit levels were significant predictors of low testosterone in the multivariate analysis.

CONCLUSION

The prevalence of low testosterone among men with acute SCI seems to be high. The results suggest the need for routine screening for low testosterone among men with SCI and consideration given to testosterone replacement therapy. Future research is needed to investigate the etiology, pathogenesis, and potential avenues for treatment of low testosterone among men with SCI.

The role of nutrition in wound care

PURPOSE

To provide the physician and registered professional nurse with an understanding of how nutrition impacts wound healing.

TARGET AUDIENCE

This continuing education activity is intended for physicians and nurses with an interest in learning more about the role nutrition plays in wound healing and how to supplement a patient's diet according to individual needs.

OBJECTIVES

After reading the article and taking the test, the participant should be able to: 1. Determine a patient's daily caloric requirements.2. Identify signs of dehydration and malnutrition. 3. Understand the role specific vitamins and minerals play in the wound healing process.

Normative hypogonadism and depression: does ‘andropause’ exist?

The progressive decline in testosterone level has been demonstrated in both cross-sectional and longitudinal studies, and overall at least 25% of men over the age of 70 years meet laboratory criteria for hypogonadism (i.e., testosterone deficiency). Such age-associated HPG hypofunctioning, which has been termed 'andropause', is thought to be responsible for a variety of symptoms experienced by elderly men, including sexual dysfunction and depression. Although, it has been difficult to establish correlations between 'andropausal' symptoms and plasma testosterone levels, there is some evidence that testosterone replacement leads to improvement in muscle strength, bone mineral density, and erectile dysfunction. There is little evidence of a link between HPG-axis dysfunction and depressive illness, and exogenous androgens have not been consistently shown to be antidepressant. This article reviews the relationship between androgens and depression in aging men.

The decline of androgen levels in elderly men and its clinical and therapeutic implications

Aging in men is accompanied by a progressive, but individually variable decline of serum testosterone production, more than 20% of healthy men over 60 yr of age presenting with serum levels below the range for young men. Albeit the clinical picture of aging in men is reminiscent of that of hypogonadism in young men and decreased testosterone production appears to play a role in part of these clinical changes in at least some elderly men, the clinical relevancy of the age-related decline in sex steroid levels in men has not been unequivocally established. In fact, minimal androgen requirements for elderly men remain poorly defined and are likely to vary between individuals. Consequently, borderline androgen deficiency cannot be reliably diagnosed in the elderly, and strict differentiation between "substitutive" and "pharmacological" androgen administration is not possible. To date, only a few hundred elderly men have received androgen therapy in the setting of a randomized, controlled study, and many of these men were not androgen deficient. Most consistent effects of treatment have been on body composition, but to date there is no evidence-based documentation of clinical benefits of androgen administration to elderly men with normal or moderately low serum testosterone in terms of diminished morbidity or of improved survival or quality of life. Until the long-term risk-benefit ratio for androgen administration to elderly is established in adequately powered trials of longer duration, androgen administration to elderly men should be reserved for the minority of elderly men who have both clear clinical symptoms of hypogonadism and frankly low serum testosterone levels.

Effects of Muscle Strength Training and Testosterone in Frail Elderly Males

PURPOSE

Determine the independent and combined effects of progressive resistance muscle strength training (PRMST) and testosterone on strength, muscle mass, and function in hypogonadal elderly male recuperative care patients.

METHODS

Between 1999 and 2004, 71 subjects (mean age 78.2 +/- 6.4 yr, 86% white) were enrolled. After baseline one-repetition maximum (1RM) strength testing and then randomization to one of four treatment groups (low-resistance (20% of the 1RM) exercises and weekly injections of either 100 mg of testosterone enanthate or placebo or high-intensity PRMST (> or =80% 1RM) and weekly injections), each subject received training and injections for 12 wk.

RESULTS

Ten subjects withdrew from the study before its completion. Based on intent-to-treat analyses, strength improved in all groups, but was greater with high-intensity PRMST compared with low-resistance exercise (e.g., leg press, (mean +/- SE), 28 +/- 4 vs 13 +/- 4%, P = 0.009). Although testosterone led to significantly greater increases in midthigh cross-sectional muscle area compared with placebo (7.9 +/- 1.3 vs 2.4 +/- 1.4%, P = 0.005), it produced only a nonsignificant trend toward greater strength gains (e.g., leg press 25 +/- 4 vs 16 +/- 4%, P = 0.144). Change in aggregate functional performance score (the sum of 4 functional performance test scores) did not differ between the four intervention groups nor with high-intensity PRMST compared with low-resistance exercise (7 +/- 5 vs 15 +/- 5%, P = 0.263). There was not a significant interaction between exercise and testosterone for any outcome.

CONCLUSION

High-intensity PRMST is as safe and well tolerated as a similarly structured low-resistance exercise regimen for very frail elderly patients, but produces greater muscle strength improvements. The addition of testosterone leads to greater muscle size and a trend toward greater strength but did not produce a synergistic interaction with exercise. Neither intervention had a significant effect on functional performance.

Frailty and the aging male

Frailty occurs in aging males for a variety of reasons. It is less common in males than females. Diseases which are particularly associated with frailty are diabetes mellitus, atherosclerosis, anemia and chronic obstructive pulmonary disease. Insulin resistance syndrome plays a pathogenetic role in the "fat-frail" syndrome. Sarcopenia occurs predominantly because of hormone deficiency and cytokine excess. Pain and anorexia are also associated with frailty. Stem cell research represents a potential promise for the treatment of frailty.

Effect of testosterone on functional recovery in a castrate male rat stroke model

Both increased and decreased testosterone levels have been reported to correlate with poor outcome after acute ischemic stroke. The present study focused on the role of testosterone during recovery from neurological deficits in a rat focal ischemia model. Castrate male rats were subjected to behavioral tests after 90 min of middle cerebral artery occlusion (MCAO). On day 7 post-MCAO, neurological deficit-matched rats were assigned to a treatment group implanted with subcutaneous testosterone pellets or a control group implanted with sham cholesterol pellets. After 4 weeks post-MCAO, the average infarct volume was not significantly different between the two groups. Rats in the testosterone group demonstrated significantly earlier improvement in neurological deficits and shortened latency of adhesive tape removal compared with the control group as analyzed by Wilcoxon signed ranks test. Walking on parallel bars improved in both groups with a trend towards early recovery observed in the testosterone group. Biased left body swings persisted during the test period in both groups post-MCAO. Serum testosterone was within physiological levels in the treatment group but was not detectable in the control group by radioimmunoassay. GAP-43 and synaptophysin expression did not differ between groups. Less GFAP expression and reactive astrocyte hypertrophy were found around the infarct area in testosterone-treated rats compared with control rats. In conclusion, testosterone replacement post-MCAO accelerated functional recovery in castrate rats, suggesting a potential therapeutic role for testosterone replacement in stroke recovery.

Glucocorticoid responses to stress in castrate and testosterone-replaced rams

Stress is an important contributor to cardiovascular disease and to reduced immunity and fertility. As the role of androgens in stress is uncertain, we investigated the effects of testosterone (T) on hormonal responses to stress in conscious Romney Marsh wethers. Six T-treated sheep and six control sheep were stressed by exposure to a psychological and a metabolic stimulus. Baseline glucose levels were significantly lower in the treated animals compared with controls (p=0.002). T treatment significantly attenuated ACTH (p<0.01) and cortisol (p<0.05) responses to metabolic stress. Following psychological stress, ACTH responses were significantly lower in treated sheep compared with controls (p<0.05), but differences in mean cortisol responses did not reach significance. There were no significant differences in epinephrine or norepinephrine responses following either stressor. We conclude that T replacement in wethers lowers glucose and attenuates responses to metabolic and psychological stress. While the implications of these results for human physiology require further studies, they suggest that male hypogonadism may play a role in determining the risk of cardiovascular disease and diabetes.

Andropause: Is Androgen Replacement Therapy Indicated for the Aging Male?

The number of men in the United States > or =65 years of age is projected to increase from 14,452,000 in 2000 to 31,343,000 in 2030. Approximately 30% of men 60-70 years of age and 70% of men 70-80 years of age have low bioavailable or free testosterone levels. Symptoms and findings of testosterone deficiency are similar to those associated with aging. They include loss of energy, depressed mood, decreased libido, erectile dysfunction, decreased muscle mass and strength, increased fat mass, frailty, osteopenia, and osteoporosis. Several small clinical trials indicate that testosterone replacement therapy can improve many of these findings; however, the studies have not been powered to assess potential risks, such as the need for invasive treatment of benign prostatic hyperplasia, development of a clinical prostate cancer, or cardiovascular events. Thus, the benefit/risk ratio of testosterone replacement therapy in aging men is not known.

Low testosterone is associated with decreased function and increased mortality risk: a preliminary study of men in a geriatric rehabilitation unit

OBJECTIVES

To evaluate whether low testosterone levels are associated with greater depression or poorer function in a geriatric rehabilitation unit.

DESIGN

Retrospective review.

SETTING

Geriatric rehabilitation unit.

MEASUREMENTS

Low testosterone levels were defined as total testosterone of 3.0 ng/mL or less or free testosterone of 9.0 pg/mL or less. Age, ethnicity, weight, depression, ambulation, length of rehabilitation, and 6-month rehospitalization and mortality rates were obtained. Overall illness severity was determined using the Cumulative Illness Rating Scale for Geriatrics.

RESULTS

Low testosterone levels were present in 29 of 44 (65.9%) men. There were no significant differences between men with low and normal testosterone levels in ethnicity, age, weight, depression, and overall illness severity. Lower testosterone levels were correlated with decreased ability to ambulate and transfer (Spearman P>.34; P<.05). There were no significant differences between men with low and normal testosterone in length of stay on the rehabilitation unit (mean+/-standard deviation= 19.6+/-11.6 vs 17.7+/-17.5 days, P=.68) or rehospitalization rates (41.4% vs 26.7%; P=.34). Men with low testosterone had a trend toward increased 6-month mortality (31.0% vs 6.7%; chi(2)=3.3, P=.07) and shorter survival time (log rank=3.2; df 1, P=.07). After entering testosterone and variables with potential prognostic significance for mortality in a stepwise manner in a Cox regression analysis, there was a significant mortality risk associated with low testosterone (hazard ratio=27.9, 95% confidence interval=2.0-384.0; P=.01).

CONCLUSION

Low testosterone levels were correlated with decreased physical function and increased risk for 6-month mortality. Prospective studies with larger sample sizes and better standardized testosterone measures are needed to confirm these findings.