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

Chronic polypharmacy, monotherapy, and deprescribing: Understanding complex effects on the hepatic proteome of aging mice

Polypharmacy (use of ≥5 concurrent medications) is highly prevalent among older adults to manage chronic diseases and is linked to adverse geriatric outcomes, including physical and cognitive functional impairments, falls, frailty, hospitalization, and mortality. Deprescribing (withdrawal) is a potential strategy to manage polypharmacy. The broad molecular changes by which polypharmacy causes harm and deprescribing may be beneficial are unknown and unfeasible to study rigorously in tissue from geriatric patients. Therefore, in a randomized controlled trial, we administered therapeutic doses of commonly used chronic medications (oxycodone, oxybutynin, citalopram, simvastatin, or metoprolol) as monotherapy or concurrently (polypharmacy) from middle-age (12 months) to old-age (26 months) to male C57BL/6J (B6) mice and deprescribed (gradually withdrew) treatments in a subset from age 21 months. We compared drug-related hepatic effects by applying proteomics along with transcriptomics and histology. We found that monotherapy effects on hepatic proteomics were limited but significant changes were seen with polypharmacy (93% unique to polypharmacy). Polypharmacy altered the hepatic expression of proteins involved in immunity, and in drug, cholesterol, and amino acid metabolism, accompanied by higher serum drug levels than monotherapies. Deprescribing not only reversed some effects but also caused irreversible and novel changes in the hepatic proteome. Furthermore, our study identified several hepatic protein co-expressed modules that are associated with clinically relevant adverse geriatric outcomes, such as mobility, frailty, and activities of daily living. This study highlights the complex molecular changes following aging, chronic polypharmacy, and deprescribing. Further exploration of these mechanistic pathways may inform management of polypharmacy and deprescribing in older adults.

Assessing the causal relationship between frailty and sex hormone-binding globulin or insulin-like growth factor-1 levels: A sex-stratified bidirectional Mendelian Randomization study

BACKGROUND

The association between frailty and sex hormone-binding globulin (SHBG) or insulin-like growth factor-1(IGF-1) levels demonstrates sex differences with inconsistent conclusions. This study aims to explore the causal relationship between frailty and SHBG or IGF-1 levels through bidirectional Mendelian randomization (MR).

METHODS

We conducted two-sample bidirectional sex-stratified MR analyses using summary-level data from genome-wide association studies (GWASs) to examine the causal relationship between frailty and IGF-1 or SHBG levels, as measured by frailty index (FI) and frailty phenotype (FP). We use the random-effects inverse-variance weighted (IVW), weighted median, MR-Egger, MR-Egger intercept, and leave-one-out approaches.

RESULT

The relationship between frailty and SHBG or IGF-1 levels is inversely related, with a significant decrease in SHBG levels in females. Specifically, SHBG levels significantly decrease with FI (β = -5.49; 95 % CI: -9.67 to -1.32; FDR = 0.02) and more pronounced with FP (β = -10.14; 95 % CI: -16.16 to -4.13; FDR = 0.01), as determined by the IVW approach. However, reverse analysis shows no significant effect of IGF-1 or SHBG levels on either FI or FP (p > 0.05).

CONCLUSION

Our study indicates a negative correlation between frailty and the levels of SHBG and IGF-1. It is suggested that further research is required to establish cut-off values for SHBG and IGF-1 levels in the frailty population. This is particularly important for females at higher risk, such as those undergoing menopause, to enable comprehensive assessment and early prevention efforts. While the findings imply that reduced IGF-1 and SHBG levels may not directly contribute to frailty, it is important not to overlook the underlying mechanisms through which they may indirectly influence frailty.

Biomarkers of frailty

Several biomarkers have been proposed to identify frailty, a multisystemic age-related syndrome. However, the complex pathophysiology and the absence of a consensus on a comprehensive and universal definition make it challenging to pinpoint a singular biomarker or set of biomarkers that conclusively characterize frailty. This review delves into the main laboratory biomarkers, placing special emphasis on those associated with various pathways closely tied to the frailty condition, such as inflammation, oxidative stress, mitochondrial dysfunction, metabolic and endocrine alterations and microRNA. Additionally, we provide a summary of different clinical biomarkers encompassing different tools that have been proposed to assess frailty. We further address various imaging biomarkers such as Dual Energy X-ray Absorptiometry, Bioelectrical Impedance analysis, Computed Tomography and Magnetic Resonance Imaging, Ultrasound and D3 Creatine dilution. Intervention to treat frailty, including non-pharmacological ones, especially those involving physical exercise and nutrition, and pharmacological interventions, that include those targeting specific mechanisms such as myostatin inhibitors, insulin sensitizer metformin and with special relevance for hormonal treatments are mentioned. We further address the levels of different biomarkers in monitoring the potential positive effects of some of these interventions. Despite the availability of numerous biomarkers, their performance and usefulness in the clinical arena are far from being satisfactory. Considering the multicausality of frailty, there is an increasing need to assess the role of sets of biomarkers and the combination between laboratory, clinical and image biomarkers, in terms of sensitivity, specificity and predictive values for the diagnosis and prognosis of the different outcomes of frailty to improve detection and monitoring of older people with frailty or at risk of developing it, being this a need in the everyday clinical practice.

The roles of sex hormones in the pathophysiology of age-related sarcopenia and frailty

Background

Sarcopenia is an age-related condition characterized by a progressive and systemic decline in skeletal muscle mass, quality, and strength. The incidence of sarcopenia contains sex-specific aspects, indicating the contribution of sex hormones to its pathophysiology. This review focuses on changing trends in sarcopenia, discusses alterations in definitions and diagnostic criteria, and emphasizes the association between sarcopenia and sex hormones.

Methods

A literature search was performed on PubMed for related articles published between 1997 and December 2023 using appropriate keywords.

Main Findings Results

Advances in research have emphasized the significance of muscle quality and strength over muscle mass, resulting in new diagnostic criteria for sarcopenia. Androgens demonstrated anabolic effects on skeletal muscles and played a significant role in the pathophysiology of sarcopenia. In clinical settings, androgen replacement therapy has exhibited certain positive outcomes for treating sarcopenia, despite concerns about potential side effects. Conversely, estrogen is involved in skeletal muscle maintenance, but the detailed mechanisms remain unclear. Moreover, results regarding the clinical application of estrogen replacement therapy for treating sarcopenia remained inconsistent.

Conclusion

The elucidation of molecular mechanisms that involve sex hormones is eagerly awaited for novel therapeutic interventions for sarcopenia.

Neurosurgical perioperative management of frail elderly patients

With the rapid increase in global aging, the prevalence of frailty is increasing and frailty has emerged as an emerging public health burden. Frail elderly patients suffer from reduced homeostatic reserve capacity, which is associated with a disproportionate decline in physical status after exposure to stress and an increased risk of adverse events. Frailty is closely associated with changes in the volume of the white and gray matter of the brain. Sarcopenia has been suggested to be an important component of frailty, and reductions in muscle strength and muscle mass lead to reductions in physical function and independence, which are critical factors contributing to poor prognosis. Approximately 10-32% of patients undergoing neurological surgery are frail, and the risk of frailty increases with age, which is significantly associated with the occurrence of adverse postoperative events (major complications, total duration of hospitalization, and need for discharge to a nursing facility). The postoperative mortality rate in severely frail patients is 9-11 times higher than that in non-frail individuals. Therefore, due attention must be paid to neurosurgical frailty and muscle assessment in elderly patients. Specialized interventions in the perioperative period of neurosurgery in frail elderly patients may improve their postoperative prognosis.

The Association between Liver Enzymes and Mortality Stratified by Non-Alcoholic Fatty Liver Disease: An Analysis of NHANES III

Associations between liver enzymes or De Ritis ratio (DRR; aspartate aminotransferase (AST)/alanine aminotransferase (ALT)) and mortality stratified by non-alcoholic fatty liver disease (NAFLD), which have rarely been analyzed in previous studies, were investigated using the National Health and Nutrition Examination Survey (NHANES) III (1988-1994). Participants without risk factors for liver diseases other than NAFLD were linked with National Death Index records through 2019 (n = 11,385) and divided into two cohorts with or without NAFLD, based on ultrasound examination. Liver enzyme concentrations were categorized into sex-specific deciles and subsequently grouped (AST and ALT: 1-3, 4-9, 10; gamma glutamyltransferase (GGT): 1-8, 9-10). DRR was categorized into tertiles. Cox proportional hazards regression models adjusted for confounders were fitted to estimate associations with mortality. Compared with low levels, high GGT and DRR in participants with and without NAFLD had significantly higher hazard ratios for all-cause mortality. Compared with intermediate concentrations, low ALT showed higher all-cause mortality in participants with and without NAFLD, whereas low AST had higher HR in participants without NAFLD and high AST in those with NAFLD. Mortality was associated with liver enzymes or DRR in participants both with and without NAFLD, indicating that the relationship is not mediated solely by hepatocellular damage.

The metabolomics of human aging: Advances, challenges, and opportunities

As the global population becomes older, understanding the impact of aging on health and disease becomes paramount. Recent advancements in multiomic technology have allowed for the high-throughput molecular characterization of aging at the population level. Metabolomics studies that analyze the small molecules in the body can provide biological information across a diversity of aging processes. Here, we review the growing body of population-scale metabolomics research on aging in humans, identifying the major trends in the field, implicated biological pathways, and how these pathways relate to health and aging. We conclude by assessing the main challenges in the research to date, opportunities for advancing the field, and the outlook for precision health applications.

SHBG, Bone Mineral Density, and Physical Function Among Injection Drug Users With and Without HIV and HCV

CONTEXT

Sex hormone-binding globulin (SHBG) is a glycoprotein that regulates the bioavailability of sex hormones and is higher in people with HIV (PWH) and hepatitis C virus (HCV). SHBG is associated with aging-related diseases, including osteoporosis and frailty in the general population. However, the relationship between SHBG concentration and bone mineral density (BMD) and physical function among PWH and HCV is unclear.

OBJECTIVE

This study aimed to evaluate the association between chronic infection with HIV and HCV and SHBG, and to assess the relationship of circulating SHBG concentrations with low BMD, physical function impairment, and frailty.

METHODS

A cross-sectional study was conducted of 278 HCV-exposed (HCV antibody positive) adults enrolled with and without HIV and HCV from the AIDS Linked to the IntraVenous Experience cohort study into 4 groups: HCV-/HIV-, HCV-/HIV+, HCV+/HIV-, and HCV+/HIV+. We evaluated the association between SHBG concentrations and grip strength, gait speed, Short Physical Performance Battery score, frailty (Fried Frailty Phenotype), and BMD (lumbar spine, total hip, and femoral neck T-score) by using adjusted multivariable regression stratified by sex.

RESULTS

SHBG concentrations were higher in women, in those with HIV RNA greater than 400 copies/mL (P = .02) and HCV RNA greater than 15 IU/mL (P < .001). In adjusted models, higher SHBG concentrations among women were statistically significantly associated with lower grip strength (-0.43 [95% CI, -0.77 to -0.081] kg/10 nmol/L, P < .05), higher odds of frailty (odds ratio, 1.49 [95% CI, 1.07 to 2.08], P < .05), and lower T-scores at the lumbar spine (-0.070 [95% CI, -0.15 to -0.001] SD/10 nmol/L T-score BMD, P < .05). Similar associations were not observed among men.

CONCLUSION

Higher SHBG concentrations are associated with the presence of HIV and HCV viremia. Among women, but not men, higher SHBG concentrations were associated with lower grip strength, higher odds of frailty, and lower lumbar spine BMD. The underlying mechanisms of these associations require further investigation.

Frailty and testosterone level in older adults: a systematic review and meta-analysis

PURPOSE

We conducted a systematic review to evaluate the relationship between total testosterone (TT), free testosterone (fT), or sex hormone-binding globulin (SHBG) and frailty in older adults.

METHODS

We systematically searched nine databases (e.g. MEDLINE, Embase, ACP Journal Club, and the Cochrane library et al.) for papers on frailty and androgen levels published up to October 10, 2021. We calculated the odds ratio (OR) for the relationship between testosterone level and frailty by performing meta-analysis.

RESULTS

The search strategy yielded 311 hits in all databases combined. Eleven (seven cross-sectional studies and four cohort studies) met the inclusion criteria for meta-analysis. Among cross-sectional studies, meta-analysis revealed a significant association between TT and frailty in men (OR = 1.37 [95% CI 1.09, 1.72]) not women (OR = 1.06 [0.84, 1.34]). The fT was also significantly association with frailty in men (OR = 1.55 [1.06, 2.25] not women (OR = 1.35 [0.91, 2.01]). Cohort studies showed the same result in TT (OR = 1.09 [1.02, 1.18]) and fT (OR = 1.15 [1.02, 1.30]) for men. We did not find a significant association between SHBG and frailty.

CONCLUSION

The findings of this systematic review and meta-analysis suggest that TT and fT were significantly associated with frailty in older men but not women.

Plasma Aromatase Activity Index, Gonadotropins and Estrone Are Associated with Frailty Syndrome in Post-Menopausal Women with Breast Cancer

Frailty syndrome is associated with poor outcomes, morbidity and premature mortality. We performed a cross-sectional study to evaluate the presence of frailty syndrome based on Fried’s frailty phenotype in post-menopausal women with breast cancer. We further analyzed the association between frailty syndrome with geriatric assessments and the association with the concentration of gonadotropins LH and FSH, estrogens, androgens and the aromatase activity index in the blood. We enrolled 47 post-menopausal women with localized breast cancer (mean age 66.8 ± 1.3 years (range 52−83)) prior to the starting of adjuvant endocrine therapy. Patients were identified as “non-frail” (robust) or “prefrail/frail” if they fulfilled at least one frailty criteria. In order to determine associations among variables and to control for other variables potentially affecting frailty syndrome (age, comorbidity index and previous chemotherapy treatment), we performed a logistic regression analysis. The receiver operating characteristic curve was performed to assess the sensitivity and specificity of the hormonal concentration to discriminate prefrail/frail versus non-frail individuals. Significant positive associations were observed between the severity of frailty syndrome and estrone, FSH and LH concentrations and the aromatase activity index in the blood (p < 0.05). Further research into the role of hormonal biomarkers should be evaluated in follow-up studies in order to recommend their use as suitable biomarkers of frailty syndrome in breast cancer patients.

Gonadotropins at Advanced Age - Perhaps They Are Not So Bad? Correlations Between Gonadotropins and Sarcopenia Indicators in Older Adults

Many hormones fluctuate during the aging process. It has been suggested that gonadotropins, which increase with age, contribute to the occurrence of many diseases and syndromes in older life, such as cardiovascular diseases, obesity, frailty syndrome and osteoporosis. This study aims to assess the relationship between circulating gonadotropins and other hormones potentially contributing to age-related functional decline and sarcopenia indicators in 39 male and 61 female community-dwelling seniors, mean age 80 years. According to the definition developed by the second European Working Group on Sarcopenia in Older People (EWGSOP2), the following indicators of the sarcopenia were assessed: bioimpedance-measured body composition, gait speed, handgrip strength, timed up and go test (TUG), chair stand test, Short Physical Performance Battery (SPPB). Blood levels of follicle-stimulating hormone (FSH), luteinizing hormone (LH), estradiol, testosterone, dehydroepiandrosterone sulphate (DHEAS) and cortisol were also measured. In the men, FSH and partially LH correlated positively with muscle mass percentage, gait speed, handgrip strength and SPPB, and negatively with percent body fat. Additionally, testosterone and DHEAS correlated negatively with the percentage of fat mass in men. Whereas in the women, FSH and LH were mainly negatively associated with body mass and adipose tissue measures. Cortisol did not show any relationship with the examined indicators. The study shows that the indicators of sarcopenia are strongly associated with levels of gonadotropins, sex hormones and DHEAS, especially in older men. The obtained results, after being confirmed in a larger group, may modify prevention and treatment strategies of sarcopenia.

Sex Differences in the Relation Between Frailty and Endothelial Dysfunction in Old Mice

Vascular endothelial function declines with age on average, but there is high variability in the magnitude of this decline within populations. Measurements of frailty, known as frailty index (FI), can be used as surrogates for biological age, but it is unknown if frailty relates to the age-related decline in vascular function. To examine this relation, we studied young (4-9 months) and old (23-32 months) C57BL6 mice of both sexes. We found that FI was greater in old compared with young mice, but did not differ between old male and female mice. Middle cerebral artery (MCA) and mesenteric artery endothelium-dependent dilation (EDD) also did not differ between old male and female mice; however, there were sex differences in the relations between FI and EDD. For the MCA, FI was inversely related to EDD among old female mice, but not old male mice. In contrast, for the mesenteric artery, FI was inversely related to EDD among old male mice, but not old female mice. A higher FI was related to a greater improvement in EDD with the superoxide scavenger TEMPOL in the MCAs for old female mice and in the mesenteric arteries for old male mice. FI related to mesenteric artery gene expression negatively for extracellular superoxide dismutase (Sod3) and positively for interleukin-1β (Il1b). In summary, we found that the relation between frailty and endothelial function is dependent on sex and the artery examined. Arterial oxidative stress and pro-inflammatory signaling are potential mediators of the relations of frailty and endothelial function.

Longitudinal Changes in Sex Hormone-Binding Globulin in Men With HIV

BACKGROUND

Sex hormone-binding globulin (SHBG) is a glycoprotein that regulates sex hormone bioavailability and increases with age in the general population. SHBG concentrations are higher in people with HIV, a population in whom accelerated aging has been hypothesized. It is unclear whether longitudinal changes in SHBG increase over time and differ by HIV serostatus.

METHODS

In a longitudinal study, SHBG was measured in 182 men with HIV (MWH) and 267 men without HIV (seronegative) from the Multicenter AIDS Cohort Study and matched for age, race, site, and time, with ≥2 SHBG serum samples over the 10 years after HAART initiation. Multivariable linear mixed-effects regression models were used to evaluate whether log-transformed SHBG [ln(SHBG)] and its rate of change differed by HIV serostatus.

RESULTS

At baseline, the mean age in MWH was similar to that in HIV-seronegative men (51 ± 5 vs 49 ± 6 years). However, SHBG mean values were higher in MWH compared with those in HIV-seronegative men (65.6 ± 48.8 vs. 45.4 ± 22 nmol/L, P < 0.001). In a fully adjusted model, SHBG increased over time and at a faster rate in MWH compared with that in HIV-seronegative men: [2.0%/year (95% CI: 1.4 to 2.7) vs 1.3%/year (95% CI: 0.8 to 1.8), respectively, P = 0.038]. Among MWH, higher SHBG concentrations were significantly associated with lower CD4+ T-cell count [β= -0.02 (95% CI: -0.03 to -0.0002), P < 0.05], fewer cumulative years on zidovudine [β = -0.027 (95% CI: -0.045 to -0.009), P < 0.001], and greater cumulative years on nonnucleoside reverse transcriptase inhibitors drugs [β = 0.022 (95% CI: 0.0006 to 0.04), P < 0.05].

CONCLUSIONS

Aging-related increases in SHBG were faster in MWH compared with those in HIV-seronegative men and were related to poorer immunologic status and antiretroviral medication exposure. The mechanisms and consequences of these findings require further investigation.

Testosterone Disorders and Male Hypogonadism in Kidney Disease

Chronic kidney disease (CKD) causes substantial alterations in the male endocrine system, which affect puberty, libido, and sexual function. A major effect of CKD is a reduction in testosterone levels because of both primary and hypogonadotrophic hypogonadism. In addition to impairment of pubertal growth and sexual maturation in children with CKD, clinical evidence suggests that uremic hypogonadism strongly contributes to several CKD complications, including erectile dysfunction, muscle wasting and frailty, anemia, decreased bone mineralization, depression, and cognitive impairment. This review focuses on a reappraisal of the physiologic role of testosterone, with an emphasis on the hypogonadal condition linked to CKD and its complications.

Angina pectoris severity and late-life frailty among men with cardiovascular disease

OBJECTIVE

We investigated the association between severity of angina pectoris (AP) and subsequent late-life frailty among men with cardiovascular disease (CVD).

METHOD

A subset of 351 men (mean age at baseline 56.7 ± 6.5 years) who previously participated in the Bezafibrate Infarction Prevention, BIP trial (1990-1997) underwent a neurovascular evaluation as part of the BIP Neurocognitive study 15.0 ± 3.0 years after baseline (T1) and a frailty evaluation according to Fried 19.9 ± 1.0 years after baseline (T2). Severity of AP was assessed at baseline of the BIP trial using the Canadian Cardiovascular Society angina classification. We assessed the odds of being in the advanced rank of frailty status (robust, pre-frail, and frail) using ordered logistic regression.

RESULTS

Among 351 participants, 134 (38.2%) were classified as pre-frail and 100 (28.5%) as frail. Frailty was found among 42% participants in the AP class ≥2 and among 26% participants in the AP class <2. Adjusting for demographic, health-related and cognitive variables, odds ratio (OR), and 95% confidence interval (95% CI) for advanced rank of frailty was 2.68 (95% CI: 1.29-5.59) comparing AP class ≥2 to AP class <2.

DISCUSSION

Among men with CVD, severity of AP should be taken into risk consideration due to its strong association with late-life frailty, particularly among inactive participants and participants with cerebral microvascular damage.

Midlife resting heart rate, but not its visit-to-visit variability, is associated with late-life frailty status in men with coronary heart disease

BACKGROUND

Autonomic imbalance is linked with multiple health conditions, yet its associations with frailty were rarely studied. We assessed the relationship of resting heart rate (RHR) and visit-to-visit heart rate variability (HRV) with future frailty among elderly men with coronary heart disease (CHD).

METHODS

Three-hundred-six community-dwelling men with CHD who participated in the Bezafibrate Infarction Prevention (BIP) trial (1990-1998; mean age 56.6 ± 6.5 years) underwent assessment of physical frailty in 2011-2013 (mean age 77.0 ± 6.4 years). Mean RHR and visit-to-visit HRV were calculated from electrocardiogram as indicators of autonomic imbalance. Nominal logistic and linear regression models were used to assess the relationships of RHR and HRV with frailty status and its components (i.e. gait speed, grip strength, weight loss, exhaustion and activity), respectively. Adjustments were made for various demographic, clinical and metabolic covariates.

RESULTS

Of the 306 men, 81 (26%) were frail and 117 (38%) were prefrail. After controlling for potential confounders, RHR, but not visit-to-visit HRV, was associated with higher odds of being prefrail [OR = 1.44 (95%CI 1.15, 1.79)] and frail [OR = 1.35 (95%CI 1.03, 1.77)]. Each 5-bpm increase in RHR was associated with weaker grip (β= -1.12 ± 0.32 kg; p-value < .001) and slower gait speed (β = 0.19 ± 0.08s/m; p-value = .022).

CONCLUSIONS

Midlife RHR may be associated with late-life frailty in men with CHD.

Physical activity and exercise: Strategies to manage frailty

Frailty, a consequence of the interaction of the aging process and certain chronic diseases, compromises functional outcomes in the elderly and substantially increases their risk for developing disabilities and other adverse outcomes. Frailty follows from the combination of several impaired physiological mechanisms affecting multiple organs and systems. And, though frailty and sarcopenia are related, they are two different conditions. Thus, strategies to preserve or improve functional status should consider systemic function in addition to muscle conditioning. Physical activity/exercise is considered one of the main strategies to counteract frailty-related physical impairment in the elderly. Exercise reduces age-related oxidative damage and chronic inflammation, increases autophagy, and improves mitochondrial function, myokine profile, insulin-like growth factor-1 (IGF-1) signaling pathway, and insulin sensitivity. Exercise interventions target resistance (strength and power), aerobic, balance, and flexibility work. Each type improves different aspects of physical functioning, though they could be combined according to need and prescribed as a multicomponent intervention. Therefore, exercise intervention programs should be prescribed based on an individual's physical functioning and adapted to the ensuing response.

Circulating biomarkers characterizing physical frailty: CRP, hemoglobin, albumin, 25OHD and free testosterone as best biomarkers. Results of a meta-analysis

INTRODUCTION

During aging, individuals can be classified as being in one of 3 different states: robust, frail or dependent. Frailty is described as reversible, so early detection offers the potential of returning the subject to a robust status. There are multiple clinical frailty scales but no gold standard and frailty is not systematically assessed in clinicians' daily practice. Reliable biomarkers of frailty are lacking, however, while their identification and systematic use would make this simple scale a useful clinical tool.

OBJECTIVE

To conduct a review of the literature concerning the biomarkers associated with frailty and to compare in a meta-analysis the plasmatic values of each biomarker in the frail with the robust group.

RESULTS

503 articles were identified on PubMed, 467 on Scopus and 369 on Web Of Science. 67 articles were included, collecting a total of 32,934 robust subjects and 6864 frail subjects. C-reactive protein (CRP) (Standardized Mean Difference (SMD): 0.49 CI 95% [0.37-0.61]) was significantly higher in the frail group whereas hemoglobin (SMD: -0.67[-0.90; -0.44]), albumin (SMD: -0.62[-0.84; -0.41]), 25-hydroxyvitamin D (25OHD) (SMD: -0.43 [-0.64; -0.21]) and, in men, free testosterone (SMD: -0.77 [-1.05; -0.49]) were significantly lower in the frail group.

CONCLUSION

We found 5 biomarkers that were associated with frailty (CRP, hemoglobin, albumin, 25OHD and free testosterone in men) belonging to multiple physiological systems. Further cohort studies are needed to verify their ability to screen for frailty.

Sleep disturbances in adults with frailty and sarcopenia

Purpose

Several epidemiological studies have reported an age-related increase in the prevalence of sleep disturbances. This study aims to investigate the relationship between sleep and sarcopenia/frailty in older adults and clarify issues that remain to be addressed in future studies.

Design/methodology/approach

PubMed was searched for relevant studies with the following keywords in the title: “sleep” and “sarcopenia” or “sleep” and “frailty.” A total of 15 studies published in English between 1998 and 2018 were reviewed.

Findings

Among the four studies that examined the relationship between sarcopenia and sleep, two reported that long or short sleep duration increased the risk of sarcopenia and this association was more pronounced in women than men. Among the seven studies examining the relationship between frailty and sleep, four reported that higher Pittsburgh Sleep Quality Index (PSQI) scores were associated with an increased risk of frailty.

Practical implications

Most previous studies have focused on interventions targeting a single area such as muscle strength or exercise habits, in older adults at risk for frailty. The results suggest that interventions targeting improved sleep may positively impact the maintenance of muscle strength.

Originality/value

The literature review revealed that too much or too little sleep increases the risk of sarcopenia in older adults. Further, sleep deprivation, greater night-time wakefulness and reduced sleep quality increase the risk of frailty. Interestingly, the risk of mortality is increased in individuals with daytime functional disorders such as excessive drowsiness or napping habits.

Risk Factors for Frailty and Cardiovascular Diseases: Are They the Same?

Cardiovascular disease burden increases with the increasing age of populations. Also, with increasing longevity, some individuals are ageing along an unfavourable path developing frailty syndrome. Epidemiologic studies indicate that frailty is overrepresented among the persons with cardiovascular disease. On the other hand, frail subjects tend to be burdened with cardiovascular disease to a greater degree than their biologically better-off peers. Hypertension, diabetes, and obesity, especially abdominal, and at least some other risk factors appear to be shared between frailty and cardiovascular disease. The probable common underlying pathophysiologic feature is inflammation and associated phenomena, possibly having its root in the inflammageing. We discuss these issues based on the results of original studies, comprehensive literature reviews, and metaanalyses, by hundreds of dedicated researchers worldwide.

Androgen-Regulated Cardiac Metabolism in Aging Men

The prevalence of cardiovascular mortality is higher in men than in age-matched premenopausal women. Gender differences are linked to circulating sex-related steroid hormone levels and their cardio-specific actions, which are critical factors involved in the prevalence and features of age-associated cardiovascular disease. In women, estrogens have been described as cardioprotective agents, while in men, testosterone is the main sex steroid hormone. The effects of testosterone as a metabolic regulator and cardioprotective agent in aging men are poorly understood. With advancing age, testosterone levels gradually decrease in men, an effect associated with increasing fat mass, decrease in lean body mass, dyslipidemia, insulin resistance and adjustment in energy substrate metabolism. Aging is associated with a decline in metabolism, characterized by modifications in cardiac function, excitation-contraction coupling, and lower efficacy to generate energy. Testosterone deficiency -as found in elderly men- rapidly becomes an epidemic condition, associated with prominent cardiometabolic disorders. Therefore, it is highly probable that senior men showing low testosterone levels will display symptoms of androgen deficiency, presenting an unfavorable metabolic profile and increased cardiovascular risk. Moreover, recent reports establish that testosterone replacement improves cardiomyocyte bioenergetics, increases glucose metabolism and reduces insulin resistance in elderly men. Thus, testosterone-related metabolic signaling and gene expression may constitute relevant therapeutic target for preventing, or treating, age- and gender-related cardiometabolic diseases in men. Here, we will discuss the impact of current evidence showing how cardiac metabolism is regulated by androgen levels in aging men.

Assessment of frailty syndrome using Edmonton frailty scale in Polish elderly sample

The aim of the study was to assess the incidence and severity of the frailty syndrome assessed with the Edmonton Frailty Scale. This is a cross-sectional study conducted among 382 patients (236 men and 146 women, mean age 71.9 years). The Edmonton Frailty Scale was administered during the patient's admission to the hospital. The Polish adaptation was performed using the standard methodology. The Cronbach's alpha coefficient for the whole Edmonton Frailty Scale was 0.709. The mean correlation between positions and the overall result was r = 0.180. There were no statistically significant differences between women and men in the area of Edmonton Frailty Scale mean score (p < 0.05). The socio-clinical analysis, showed statistically significant differences in the age of respondents, educational attainment, occupational activity, number of drugs taken and co-occurrence of chronic diseases. A higher values of the Edmonton Frailty Scale were indicated for individuals >70 years than for those <70 years (p < 0.001). The Edmonton Frailty Scale proved to be a reliable tool which may be used in the Polish population. The use of this questionnaire for frailty syndrome may be helpful in everyday clinical practice.

Steroid secretion in healthy aging

Nowadays, people spend a considerable amount of their lives as older adults, but this longer lifespan is often accompanied by an increase in chronic conditions and disease, resulting in reduced quality of life and unprecedented societal and economic burden. Healthy aging is therefore increasingly recognized as a healthcare priority. Physical and mental adaptations to changes over the life course, and the maintenance of well-being, represent pivotal challenges in healthy aging. To capture the complexity of healthy aging, we propose a specific phenotype based on body composition, cognition, mood, and sexual function as indicators of different dimensions of healthy aging. With increasing age, sex hormones as well as glucocorticoids undergo significant alterations, and different patterns emerge for women and men. This review describes age-related patterns of change for women and men, and sheds light on the underlying mechanisms. Furthermore, an overview is provided of the challenges for healthy aging resulting from these age-related steroid alterations. While clinical practice guidelines recommend hormonal treatment only in the case of consistently low hormone levels and symptoms of hormone deficiency, physical exercise and a healthy lifestyle emerge as preventive strategies which can counter age-related hormonal changes and at best prevent chronic conditions.

Frailty and Rejuvenation with Stem Cells: Therapeutic Opportunities and Clinical Challenges

Frailty, one appealing target for improving successful aging of the elderly population, is a common clinical syndrome based on the accumulation of multisystemic function declines and the increase in susceptibility to stressors during biological aging. The age-dependent senescence, the frailty-related stem cell depletion, chronic inflammation, imbalance of immune homeostasis, and the reduction of multipotent stem cells collectively suggest the rational hypothesis that it is possible to (partially) cure frailty with stem cells. This systematic review has included all of the human trials of stem cell therapy for frailty from the main electronic databases and printed materials and screened the closely related reviews themed on the mechanisms of aging, frailty, and stem cells, to provide more insights in stem cell strategies for frailty, one promising method to recover health from a frail status. To date, a total of four trials about this subject have been registered on clinicaltrials.gov. The use of mesenchymal stem cells (MSCs), doses of 100 million cells, single peripheral intravenous infusion, follow-up periods of 6–12 months, and a focus primarily on safety and secondarily on efficacy are common characteristics of these studies. We conclude that intravenous infusion of allogenic MSCs is safe, well tolerated, and preliminarily effective clinically. More preclinical experiments and clinical trials are warranted to precisely elucidate the mechanism, safety, and efficacy of frailty stem cell therapy.

Frailty and Long-Term Post-Kidney Transplant Outcomes

PURPOSE OF REVIEW

To highlight recent research about frailty and its role as a predictor of adverse, long-term post-kidney transplant (KT) outcomes.

RECENT FINDINGS

Frailty is easily measured using the physical frailty phenotype (PFP) developed by gerontologist Dr. Linda Fried and colleagues. In recent studies, >50% of KT recipients were frail (20%) or intermediately frail (32%) at KT admission. Frail recipients were at 1.3-times higher risk of immunosuppression intolerance and 2.2-times higher risk of mortality, even after accounting for recipient, donor, and transplant factors; these findings were consistent with those on short-term post-KT outcomes. Pilot data suggests that prehabilitation may be an intervention that increases physiologic reserve in frail KT recipients.

SUMMARY

The PFP is a effective tool to measure frailty in ESRD that improves risk stratification for short-term and long-term post-KT outcomes. Interventions to improve physiologic reserve and prevent adverse KT outcomes, particularly among frail KT recipients, are needed.

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

OBJECTIVES

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

DESIGN

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

SETTING

Four U.S clinical centers.

PARTICIPANTS

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

MEASUREMENTS

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

RESULTS

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

CONCLUSION

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

Frailty and the endocrine system

Frailty is a condition characterised by loss of biological reserves, failure of homoeostatic mechanisms, and vulnerability to adverse outcomes. The endocrine system is considered particularly important in frailty, because of its complex inter-relationships with the brain, immune system, and skeletal muscle. This Review summarises evidence indicating a key role for the hypothalamic-pituitary axis in the pathogenesis of frailty through aberrant regulation of glucocorticoid secretion, insulin-like growth factor signalling, and androgen production. Evidence also indicates a potential role for vitamin D and insulin resistance in the pathogenesis of frailty. The role of thyroid hormones in the pathogenesis of frailty remains uncertain. Key convergent pathological effects of frailty include loss of muscle mass and strength, with consequent impact on mobility and activities of daily living. Future translational research should focus on the understanding of endocrine mechanisms, to identify potential biomarkers of the condition, modifiable targets for treatment, and novel pharmacological drugs targeted at the endocrine components of frailty.

Frailty assessment in older adults with chronic obstructive respiratory diseases

The number of patients with chronic obstructive pulmonary disease (COPD) has been rising with continued exposure to environmental risk factors and aging of populations around the world. Frailty is a geriatric syndrome with a decline in physiological reserve and often coexists with chronic diseases such as COPD. Frailty is an independent risk factor for the development and progression of COPD, and COPD can lead to frailty; treating one might improve the other. Thus, there is an increasing interest in the assessment of frailty in patients with COPD. Furthermore, early identification and assessment of frailty in patients with COPD may affect the choice of intervention and improve its effectiveness. Based on the current literature, the intent of this review was to summarize and discuss frailty assessment tools used for COPD patients and the relevant clinical practices for predicting outcomes. We ascertain that using suitable frailty assessment tools could facilitate physicians to screen and stratify physically frail patients with COPD. Screening appropriately targeted population can achieve better intervention outcomes and pulmonary rehabilitation among frail COPD patients.

Testosterone, frailty and physical function in older men

INTRODUCTION

Age-related decline in serum testosterone (T) has been suggested in some studies to be associated with individual components of frailty: diminished energy, muscle strength and physical function.

AREAS COVERED

The aim of this study is to comprehensively review evidence from observational and interventional studies on the relationship of T to frailty in older men. We reviewed observational studies exploring the relationship between circulating T and its potent metabolite dihydrotestosterone (DHT) with frailty. We further reviewed the effects of T treatment on lean mass, muscle strength and physical function in both frail and non-frail older men.

EXPERT COMMENTARY

T treatment may provide modest improvements in lean mass among both frail and non-frail older men, but current evidence on the T effect on muscle strength is conflicting and the effect on physical function is weak.

Benefits and Health Implications of Testosterone Therapy in Men With Testosterone Deficiency

INTRODUCTION

Testosterone (T) deficiency (TD; hypogonadism) has deleterious effects on men's health; negatively affects glycometabolic and cardiometabolic functions, body composition, and bone mineral density; contributes to anemia and sexual dysfunction; and lowers quality of life. T therapy (TTh) has been used for the past 8 decades to treat TD, with positive effects on signs and symptoms of TD.

AIM

To summarize the health benefits of TTh in men with TD.

METHODS

A comprehensive literature search was carried out using PubMed, articles relevant to TTh were accessed and evaluated, and a comprehensive summary was synthesized.

MAIN OUTCOME MEASURES

Improvements in signs and symptoms of TD reported in observational studies, registries, clinical trials, and meta-analyses were reviewed and summarized.

RESULTS

A large body of evidence provides significant valuable information pertaining to the therapeutic value of TTh in men with TD. TTh in men with TD provides real health benefits for bone mineral density, anemia, sexual function, glycometabolic and cardiometabolic function, and improvements in body composition, anthropometric parameters, and quality of life.

CONCLUSION

TTh in the physiologic range for men with TD is a safe and effective therapeutic modality and imparts great benefits on men's health and quality of life. Traish AM. Benefits and Health Implications of Testosterone Therapy in Men With Testosterone Deficiency. Sex Med Rev 2018;6:86-105.

Aging and sex hormones in males

Several large cohort studies have disclosed the trajectories of sex steroids changes overtime in men and their clinical significance. In men the slow, physiological decline of serum testosterone (T) with advancing age overlaps with the clinical condition of overt, pathological hypogonadism. In addition, the increasing number of comorbidities, together with the high prevalence of chronic diseases, all further contribute to the decrease of serum T concentrations in the aging male. For all these reasons both the diagnosis of late-onset hypogonadism (LOH) in men and the decision about starting or not T replacement treatment remain challenging. At present, the biochemical finding of T deficiency alone is not sufficient for diagnosing hypogonadism in older men. Coupling hypogonadal symptoms with documented low serum T represents the best strategy to refine the diagnosis of hypogonadism in older men and to avoid unnecessary treatments.

Association of the modified frailty index with adverse outcomes after penile prosthesis implantation

OBJECTIVES

To investigate frailty as a predictor of surgical outcome in elderly patients undergoing penile prosthesis implantation.

MATERIAL AND METHODS

A total of 54 elderly patients, above 60 years of age, underwent penile prosthesis implantation between 2012 and 2014. Their data were collected and retrospectively analyzed. A modified frailty index (mFI) was calculated for each patient based on 11 risk factors from the Canadian Study of Health and Aging Frailty Index. The 1-year adverse outcomes were correlated with mFI, patients' and procedure's risk factors.

RESULTS

Mean age was 64.9 ± 5.2 years. No mortality was reported in our patients, however, one-year adverse outcomes were encountered in 43 (79.6%) patients. Among all studied variables, the 1-year adverse outcomes was not significantly association with mFI, but with preoperative glycosylated hemoglobin A1c (HbA1c) (p = 0.031) and associated Peyronie's disease (PD) (p = 0.000). HbA1c, dyslipidemia, hypertension, PD and duration of the procedure were predictive of infection complications (p < 0.05). Only PD and HbA1c sustained an independent significant impact.

CONCLUSIONS

mFI is not a predictive of post-penile prosthesis implantation adverse outcomes in elderly patients with impotence. Degree of diabetic control and association with PD was associated with the 1-year adverse outcomes and infection complications.

Risk of cardiovascular disease morbidity and mortality in frail and pre-frail older adults: Results from a meta-analysis and exploratory meta-regression analysis

Frailty is common and associated with poorer outcomes in the elderly, but its role as potential cardiovascular disease (CVD) risk factor requires clarification. We thus aimed to meta-analytically evaluate the evidence of frailty and pre-frailty as risk factors for CVD. Two reviewers selected all studies comparing data about CVD prevalence or incidence rates between frail/pre-frail vs. robust. The association between frailty status and CVD in cross-sectional studies was explored by calculating and pooling crude and adjusted odds ratios (ORs) ±95% confidence intervals (CIs); the data from longitudinal studies were pooled using the adjusted hazard ratios (HRs). Eighteen cohorts with a total of 31,343 participants were meta-analyzed. Using estimates from 10 cross-sectional cohorts, both frailty and pre-frailty were associated with higher odds of CVD than robust participants. Longitudinal data were obtained from 6 prospective cohort studies. After a median follow-up of 4.4 years, we identified an increased risk for faster onset of any-type CVD in the frail (HR=1.70 [95%CI, 1.18-2.45]; I2=66%) and pre-frail (HR=1.23 [95%CI, 1.07-1.36]; I2=67%) vs. robust groups. Similar results were apparent for time to CVD mortality in the frail and pre-frail groups. In conclusion, frailty and pre-frailty constitute addressable and independent risk factors for CVD in older adults.

Testosterone therapy in men with testosterone deficiency: Are we beyond the point of no return?

Although testosterone therapy in men with testosterone deficiency was introduced in the early 1940s, utilization of this effective treatment approach in hypogonadal men is met with considerable skepticism and resistance. Indeed, for decades, the fear that testosterone may cause prostate cancer has hampered clinical progress in this field. Nevertheless, even after considerable knowledge was acquired that this fear is unsubstantiated, many in the medical community remain hesitant to utilize this therapeutic approach to treat men with hypogonadism. As the fears concerning prostate cancer have subsided, a new controversy regarding use of testosterone therapy and increase in cardiovascular disease was introduced. Although the new controversy was based on one ill-fated clinical trial, one meta-analysis with studies that utilized unapproved formulation in men with liver cirrhosis, and two retrospective studies with suspect or nonvalidated statistical methodologies and database contaminations, the flames of such controversy were fanned by the lay press and academics alike. In this review we discuss the adverse effect of testosterone deficiency and highlight the numerous proven benefits of testosterone therapy on men's health and debunk the myth that testosterone therapy increases cardiovascular risk. Ultimately, we believe that there is considerable scientific and clinical evidence to suggest that testosterone therapy is safe and effective with restoration of physiological levels in men with testosterone deficiency, irrespective of its etiology.

Frailty and sarcopenia as the basis for the phenotypic manifestation of chronic diseases in older adults

Frailty is a functional status that precedes disability and is characterized by decreased functional reserve and increased vulnerability. In addition to disability, the frailty phenotype predicts falls, institutionalization, hospitalization and mortality. Frailty is the consequence of the interaction between the aging process and some chronic diseases and conditions that compromise functional systems and finally produce sarcopenia. Many of the clinical manifestations of frailty are explained by sarcopenia which is closely related to poor physical performance. Reduced regenerative capacity, malperfusion, oxidative stress, mitochondrial dysfunction and inflammation compose the sarcopenic skeletal muscle alterations associated to the frailty phenotype. Inflammation appears as a common determinant for chronic diseases, sarcopenia and frailty. The strategies to prevent the frailty phenotype include an adequate amount of physical activity and exercise as well as pharmacological interventions such as myostatin inhibitors and specific androgen receptor modulators. Cell response to stress pathways such as Nrf2, sirtuins and klotho could be considered as future therapeutic interventions for the management of frailty phenotype and aging-related chronic diseases.

Hypogonadism and erectile dysfunction as harbingers of systemic disease

Prescription sales of Testosterone and erectile aids such as phosphodiesterase-5 inhibitors are at an all-time high, underscoring the importance of hypogonadism (HG) and erectile dysfunction (ED) to men’s health. The effect of these debilitating conditions has a major impact on the quality of men’s lives. Some risk factors for HG or ED including aging, obesity, smoking, and a sedentary lifestyle. Notably, these are the same risk factors for several other medical co-morbidities that contribute to significant morbidity and mortality in men. HG and ED often co-exist with cardiovascular disease, diabetes, and osteoporosis. This review will explore these three co-morbidities that overlap with HG and ED, and will provide a review of their relationship with each other.

Hypothalamic-pituitary-adrenal (HPA) axis and aging

Human aging is associated with increasing frailty and morbidity which can result in significant disability. Dysfunction of the hypothalamic-pituitary-adrenal (HPA) axis may contribute to aging-related diseases like depression, cognitive deficits, and Alzheimer's disease in some older individuals. In addition to neuro-cognitive dysfunction, it has also been associated with declining physical performance possibly due to sarcopenia. This article reviews the pathophysiology of HPA dysfunction with respect to increased basal adrenocorticotropic hormone (ACTH) and cortisol secretion, decreased glucocorticoid (GC) negative feedback at the level of the paraventricular nucleus (PVN) of the hypothalamus, hippocampus (HC), and prefrontal cortex (PFC), and flattening of diurnal pattern of cortisol release. It is possible that the increased cortisol secretion is secondary to peripheral conversion from cortisone. There is a decline in pregnolone secretion and C-19 steroids (DHEA) with aging. There is a small decrease in aldosterone with aging, but a subset of the older population have a genetic predisposition to develop hyperaldosteronism due to the increased ACTH stimulation. The understanding of the HPA axis and aging remains a complex area with conflicting studies leading to controversial interpretations.

Moderate weight loss in obese and overweight men preserves bone quality

BACKGROUND

Weight loss (WL) negatively affects bone mineral density (BMD) in older populations and has specifically been shown in women.

OBJECTIVE

In this prospective controlled trial, we examined variables of bone quality and endocrine changes after intentional WL in men.

DESIGN

Thirty-eight overweight and obese [mean ± SD body mass index (in kg/m²): 31.9 ± 4.4; age: 58 ± 6 y] men were recruited to either WL through caloric restriction or weight maintenance (WM) for 6 mo.

RESULTS

There was a -7.9 ± 4.4% and +0.2 ± 1.6% change in body weight in the WL and WM groups, respectively. There was a greater increase in femoral neck and total body BMD and bone mineral content (BMC) in the WM group than in the WL group (P-interaction effect < 0.05). In contrast, there was a trend for the tibia cortical thickness and area to decrease more in the WM group than in the WL group (P ≤ 0.08). There was a decrease in the periosteal circumference in both groups over time (P < 0.01) and no statistically significant changes in trabecular bone. Circulating total, free, and bioavailable estradiol decreased in the WL group compared with the WM group, and changes were different between groups (P < 0.05). Serum total and bioavailable testosterone increased in both groups (P < 0.01). Serum 25-hydroxyvitamin D increased to a similar extent in both groups (P < 0.05).

CONCLUSIONS

Moderate WL in overweight and obese men did not decrease BMD at any anatomical site or alter cortical and trabecular bone and geometry. Also, despite increased BMD at some sites when maintaining excess body weight, cortical bone showed a trend in the opposite direction.

Androgen effects on skeletal muscle: implications for the development and management of frailty

Androgens have potent anabolic effects on skeletal muscle and decline with age in parallel to losses in muscle mass and strength. This loss of muscle mass and function, known as sarcopenia, is the central event in development of frailty, the vulnerable health status that presages adverse outcomes and rapid functional decline in older adults. The potential role of falling androgen levels in the development of frailty and their utility as function promoting therapies in older men has therefore attracted considerable attention. This review summarizes current concepts and definitions in muscle ageing, sarcopenia and frailty, and evaluates recent developments in the study of androgens and frailty. Current evidence from observational and interventional studies strongly supports an effect of androgens on muscle mass in ageing men, but effects on muscle strength and particularly physical function have been less clear. Androgen treatment has been generally well–tolerated in studies of older men, but concerns remain over higher dose treatments and use in populations with high cardiovascular risk. The first trials of selective androgen receptor modulators (SARMs) suggest similar effects on muscle mass and function to traditional androgen therapies in older adults. Important future directions include the use of these agents in combination with exercise training to promote functional ability across different populations of older adults, as well as more focus on the relationships between concurrent changes in hormone levels, body composition and physical function in observational studies.

Clinical features of prefrail older individuals and emerging peripheral biomarkers: a systematic review

Frailty is a geriatric syndrome characterized by the clinical presentation of identifiable physical alterations such as loss of muscle mass and strength, energy and exercise tolerance, and decreased physiological reserve. Individuals with one or two of these alterations are defined as prefrail. The clinical features of prefrail older individuals have been investigated to a lesser extent compared to the frail population, even though this intermediate stage may provide insights into the mechanisms involved in the physical decline associated with aging and it is considered to be potentially reversible. We performed searches in the Medline, Embase, Scopus, Cinahl, and Cochrane databases from January 1995 to July 2013 for papers about the identification of prefrail people aged 65 and older published either in English or Spanish, and the reference lists of from the articles retrieved were pearled in order to identify any which may have been missed in the initial search. Two independent reviewers extracted descriptive information on frailty criteria and outcomes from the selected papers: of the 277 articles retrieved from the searches and 25 articles retrieved from pearling, 84 met the study inclusion criteria. The prevalence of prefrailty ranges between 35% and 50% in individuals aged over 60, is more common in women, and the age and the number of comorbidities in these individuals is similar to their frail counterparts. Weakness is the most prevalent symptom in prefrail individuals although there are some sex differences. Some serum biomarkers seem to discriminate prefrail from non-frail individuals but further research would be required to confirm this.

Sarcopenic obesity: how do we treat it?

PURPOSE OF REVIEW

The increasing prevalence of sarcopenic obesity in older adults has heightened interest in identifying the most effective treatment. This review highlights recent progress in the management, with an emphasis on lifestyle interventions and pharmacologic therapy aimed at reversing sarcopenic obesity.

RECENT FINDINGS

Whereas weight loss and exercise independently reverse sarcopenic obesity, they act synergistically in combination to improve body composition and physical function, beyond which is observed with either intervention alone. Optimizing protein intake appears to have beneficial effects on net muscle protein accretion in older adults. Myostatin inhibition is associated with favorable changes in body composition in animal studies, although experience in humans is relatively limited. Testosterone and growth hormone offer improvements in body composition, but the benefits must be weighed against potential risks of therapy. GHRH-analog therapy shows promise, but further studies are needed in older adults.

SUMMARY

At present, lifestyle interventions incorporating both diet-induced weight loss and regular exercise appear to be the optimal treatment for sarcopenic obesity. Maintenance of adequate protein intake is also advisable. Ongoing studies will determine whether pharmacologic therapy such as myostatin inhibitors or GHRH analogs have a role in the treatment of sarcopenic obesity.

Frailty, sarcopenia, and hormones

Frailty is now a definable clinical syndrome with a simple screening test. Age-related changes in hormones play a major role in the development of frailty by reducing muscle mass and strength (sarcopenia). Selective Androgen Receptor Molecules and ghrelin agonists are being developed to treat sarcopenia. The role of Activin Type IIB soluble receptors and Follistatin-like 3 mimetics is less certain because of side effects. Exercise (resistance and aerobic), vitamin D and protein supplementation, and reduction of polypharmacy are keys to the treatment of frailty.

Low total testosterone levels are associated with the metabolic syndrome in elderly men: the role of body weight, lipids, insulin resistance, and inflammation; the Ikaria study

BACKGROUND

The prevalence of the metabolic syndrome (MetS) increases with age. Among other changes, testosterone levels decline with age. The relationship between testosterone levels and MetS components in older subjects has not been clearly defined until today.

OBJECTIVES

The aim of this work was to evaluate the relationship between total serum testosterone levels and MetS and its components.

METHODS

The working sample consisted of 467 elderly individuals (mean age 75 ± 6 years old, n = 220 men) from Ikaria Island, Greece. MetS was defined according to the NCEP ATPIII criteria.

RESULTS

MetS prevalence was 52% in men and 64% in women. Those with MetS had lower testosterone levels; a 10 ng/dl increase in testosterone was associated with a 3% reduction in odds of having MetS in men (95% CI: 0.95-0.99), but not in women. This remained the result after various adjustments had been made, including daily hours of sleep. Testosterone was inversely associated with abnormal waist circumference, high-sensitivity C-reactive protein (hs-CRP), insulin, and HDL cholesterol levels in men only. When lipid categories, hs-CRP, BMI, and insulin resistance levels were taken into account, testosterone lost its significance in predicting MetS (p < 0.20), suggesting that these markers possess a mediating effect.

CONCLUSIONS

In elderly men, low serum testosterone was associated with MetS. Lipids, BMI, inflammation, and insulin resistance levels seem to explain this relationship, suggesting a potential mediating effect. This finding may support a research hypothesis relating serum testosterone to cardiovascular disease, which requires further research.