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Braendle K, Egli A, Bischoff-Ferrari H, Freystaetter G. Does living alone influence fall risk among Swiss older adults aged 60+? A pooled observational analysis of three RCTs on fall prevention. BMJ Open 2024; 14:e081413. [PMID: 38772577 PMCID: PMC11110580 DOI: 10.1136/bmjopen-2023-081413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 04/17/2024] [Indexed: 05/23/2024] Open
Abstract
OBJECTIVES Falling and living alone have been identified as public health challenges in an ageing society. Our study investigates whether living alone influences fall risk in community-dwelling older adults in Switzerland. DESIGN AND METHODS Secondary analysis of three randomised controlled trials investigating how different doses of vitamin D and an exercise programme may influence the risk of further falls in people 60+ at risk of falling. We used logistic regression to examine the association between living alone and the odds of becoming a faller, and negative binomial regression to examine the association between living alone and the rate of falls. We assessed both any falls and falls with injury. All analyses were adjusted for sex, body mass index, age, grip strength, comorbidities, use of walking aids, mental health, trial and treatment group. Predefined subgroups were by sex and age. RESULTS Among 494 participants (63% women; mean age was 74.7±7.5 years) 643 falls were recorded over 936.5 person-years, including 402 injurious falls. Living alone was associated with a 1.76-fold higher odds of becoming a faller (OR (95% CI)=1.76 (1.11 to 2.79)). While the odds did not differ by sex, older age above the median age of 74.6 years increased the odds to 2.19-fold (OR (95% CI)=2.19 (1.11 to 4.32)). The rate of total or injurious falls did not differ by living status. CONCLUSIONS Community-dwelling older adults living alone have a higher odds of becoming a faller. The increased odds is similar for men and women but accentuated with higher age. TRIAL REGISTRATION NUMBERS ZDPT: NCT01017354, NFP53: NCT00133640, OA: NCT00599807.
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Affiliation(s)
- Kilian Braendle
- Center on Aging and Mobility, University of Zurich, Zurich, Switzerland
- Department of Aging Medicine and Aging Research, University of Zurich, Zurich, Switzerland
| | - Andreas Egli
- Center on Aging and Mobility, University of Zurich, Zurich, Switzerland
- Department of Aging Medicine and Aging Research, University of Zurich, Zurich, Switzerland
| | - Heike Bischoff-Ferrari
- Center on Aging and Mobility, University of Zurich, Zurich, Switzerland
- Department of Aging Medicine and Aging Research, University of Zurich, Zurich, Switzerland
- IHU HealthAge, University Hospital Toulouse and University III Toulouse Paul Sabatier, Toulouse, France
| | - Gregor Freystaetter
- Center on Aging and Mobility, University of Zurich, Zurich, Switzerland
- Department of Aging Medicine and Aging Research, University of Zurich, Zurich, Switzerland
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Bischoff-Ferrari HA, Gagesch M, Tsai DH, Richter C, Lanz P, Sidler P, Can U, Keller DI, Minder M, von Rickenbach B, Yildirim-Aman A, Geiling K, Freystaetter G. Validation of the ICEBERG emergency room screening tool for early identification of older patients with geriatric consultation needs. Front Med (Lausanne) 2023; 10:1240082. [PMID: 37828937 PMCID: PMC10565002 DOI: 10.3389/fmed.2023.1240082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 09/11/2023] [Indexed: 10/14/2023] Open
Abstract
Background The growing number of older and oldest-old patients often present in the emergency room (ER) with undiagnosed geriatric syndromes posing them at high risk for complications in acute care. Objective To develop and validate an ER screening tool (ICEBERG) to capture 9 geriatric domains of risk in older patients. Design setting and participants For construct validity we performed a chart-based study in 129 ER patients age 70 years and older admitted to acute geriatric care (pilot 1). For criterion validity we performed a prospective study in 288 ER patients age 70 years and older admitted to acute care (pilot 2). Exposure In both validation steps, the exposure was ICEBERG test performance below and above the median score (10, range 0-30). Outcome measures and analysis In pilot 1, we compared the exposure with results of nine tests of the Comprehensive Geriatric Assessment (CGA). In pilot 2, we compared the exposure assessed in the ER to following length of hospital stay (LOS), one-on-one nursing care needs, in-hospital mortality, 30-day re-admission rate, and discharge to a nursing home. Main results Mean age was 82.9 years (SD 6.7; n = 129) in pilot 1, and 81.5 years (SD 7.0; n = 288) in pilot 2. In pilot 1, scoring ≥10 was associated with significantly worse performance in 8 of 9 of the individual CGA tests. In pilot 2, scoring ≥10 resulted in longer average LOS (median 7 days, IQR 4, 11 vs. 6 days, IQR 3, 8) and higher nursing care needs (median 1,838 min, IQR 901, 4,267 vs. median 1,393 min, IQR 743, 2,390). Scoring ≥10 also increased the odds of one-on-one nursing care 2.9-fold (OR 2.86, 95%CI 1.17-6.98), and the odds of discharge to a nursing home 3.7-fold (OR 3.70, 95%CI 1.74-7.85). Further, scoring ≥10 was associated with higher in-hospital mortality and re-hospitalization rates, however not reaching statistical significance. Average time to complete the ICEBERG tool was 4.3 min (SD 1.3). Conclusion Our validation studies support construct validity of the ICEBERG tool with the CGA, and criterion validity with several clinical indicators in acute care.
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Affiliation(s)
- Heike A. Bischoff-Ferrari
- Center on Aging and Mobility, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- University Clinic for Aging Medicine, City Hospital Zurich, Zurich, Switzerland
- Department of Aging Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Michael Gagesch
- Center on Aging and Mobility, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- Department of Aging Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Dai-Hua Tsai
- Center on Aging and Mobility, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Clara Richter
- Center on Aging and Mobility, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Patricia Lanz
- University Clinic for Aging Medicine, City Hospital Zurich, Zurich, Switzerland
| | - Patrick Sidler
- Institute for Emergency Medicine, City Hospital Zurich, Zurich, Switzerland
| | - Uenal Can
- Institute for Emergency Medicine, City Hospital Zurich, Zurich, Switzerland
| | - Dagmar I. Keller
- Institute for Emergency Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Markus Minder
- Center for Aging Medicine and Palliative Care, Hospital Affoltern, Affoltern, Switzerland
| | - Bettina von Rickenbach
- Center for Aging Medicine and Palliative Care, Hospital Affoltern, Affoltern, Switzerland
| | - Ali Yildirim-Aman
- Interdisciplinary Emergency Center, Hospital Affoltern, Affoltern, Switzerland
| | - Katharina Geiling
- Center on Aging and Mobility, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- Department of Aging Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Gregor Freystaetter
- Center on Aging and Mobility, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- Department of Aging Medicine, University Hospital Zurich, Zurich, Switzerland
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Gagesch M, Wieczorek M, Abderhalden LA, Lang W, Freystaetter G, Armbrecht G, Kressig RW, Vellas B, Rizzoli R, Blauth M, Orav EJ, Egli A, Bischoff-Ferrari HA. Grip strength cut-points from the Swiss DO-HEALTH population. Eur Rev Aging Phys Act 2023; 20:13. [PMID: 37543639 PMCID: PMC10403936 DOI: 10.1186/s11556-023-00323-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 07/25/2023] [Indexed: 08/07/2023] Open
Abstract
BACKGROUND While grip strength (GS) is commonly assessed using a Dynamometer, the Martin Vigorimeter was proposed as an alternative method especially in older adults. However, its reference values for Swiss older adults are missing. We therefore aimed to derive sex- and age-specific GS cut-points for the dominant and non-dominant hand (DH; NDH) using the Martin Vigorimeter. Additionally, we aimed to identify clinically relevant weakness and assess convergent validity with key markers of physical function and sarcopenia in generally healthy Swiss older adults. METHODS This cross-sectional analysis includes baseline data from Swiss participants enrolled in DO-HEALTH, a 3-year randomized controlled trial in community-dwelling adults age 70 + . For both DH and NDH, 4 different definitions of weakness to derive GS cut-points by sex and age category (≤ 75 vs. > 75 years) were used: i) GS below the median of the 1st quintile, ii) GS below the upper limit of the 1st quintile, iii) GS below 2-standard deviation (SD) of the sex- and age-specific mean in DO-HEALTH Swiss healthy agers (i.e. individuals without major chronic diseases, disabilities, cognitive impairment or mental health issues) and iv) GS below 2.5-SD of the sex- and age-specific mean in DO-HEALTH Swiss healthy agers. To assess the proposed cut-points' convergent validity, we assessed their association with gait speed, time to complete the 5 Times Sit-To-Stand (5TSTS) test, and present sarcopenia. RESULTS In total, 976 participants had available GS at the DH (mean age 75.2, 62% women). According to the 4 weakness definitions, GS cut-points at the DH ranged from 29-42 and 25-39 kPa in younger and older women respectively, and from 51-69 and 31-50 kPa in younger and older men respectively. Overall, weakness prevalence ranged from 2.0% to 19.3%. Definitions of weakness using the median and the upper limit of the 1st GS quintile were most consistently associated with markers of physical performance. Weak participants were more likely to have lower gait speed, longer time to complete the 5TSTS, and sarcopenia, compared to participants without weakness. CONCLUSIONS In generally healthy Swiss older adults, weakness defined by the median or the upper limit of the 1st GS quintile may serve as reference to identify clinically relevant weakness. Additional research is needed in less healthy populations in order to derive representative population-based cut-points. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01745263.
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Affiliation(s)
- Michael Gagesch
- Department of Aging Medicine and Aging Research, University Hospital Zurich and University of Zurich, Zurich, Switzerland.
- Center On Aging and Mobility, University Hospital Zurich, City Hospital Zurich Waid and University of Zurich, Zurich, Switzerland.
| | - Maud Wieczorek
- Center On Aging and Mobility, University Hospital Zurich, City Hospital Zurich Waid and University of Zurich, Zurich, Switzerland
| | - Lauren A Abderhalden
- Center On Aging and Mobility, University Hospital Zurich, City Hospital Zurich Waid and University of Zurich, Zurich, Switzerland
| | - Wei Lang
- Center On Aging and Mobility, University Hospital Zurich, City Hospital Zurich Waid and University of Zurich, Zurich, Switzerland
| | - Gregor Freystaetter
- Department of Aging Medicine and Aging Research, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- Center On Aging and Mobility, University Hospital Zurich, City Hospital Zurich Waid and University of Zurich, Zurich, Switzerland
| | - Gabriele Armbrecht
- Department of Radiology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
| | - Reto W Kressig
- University Department of Geriatric Medicine FELIX PLATTER, Basel, Switzerland
| | - Bruno Vellas
- UMR INSERM 1027, Gérontopôle, Toulouse University Hospital, University of Toulouse, Toulouse, France
- IHU HealthAge, University Hospital Toulouse, Toulouse, France
| | - René Rizzoli
- Service of Bone Diseases, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | | | - E John Orav
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Andreas Egli
- Center On Aging and Mobility, University Hospital Zurich, City Hospital Zurich Waid and University of Zurich, Zurich, Switzerland
| | - Heike A Bischoff-Ferrari
- Department of Aging Medicine and Aging Research, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- Center On Aging and Mobility, University Hospital Zurich, City Hospital Zurich Waid and University of Zurich, Zurich, Switzerland
- IHU HealthAge, University Hospital Toulouse, Toulouse, France
- University Clinic for Acute Geriatric Care, City Hospital Waid and Triemli, Zurich, Switzerland
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de Godoi Rezende Costa Molino C, Rübel L, Mantegazza N, Bischoff-Ferrari HA, Freystaetter G. Association of polypharmacy with cognitive impairment in older trauma patients: a cross-sectional study. Eur J Hosp Pharm 2023:ejhpharm-2022-003645. [PMID: 36882299 DOI: 10.1136/ejhpharm-2022-003645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 02/21/2023] [Indexed: 03/09/2023] Open
Abstract
INTRODUCTION Few if any studies have been conducted to date on the association between polypharmacy and cognitive impairment among older trauma patients. Therefore, we investigated whether polypharmacy is associated with cognitive impairment in trauma patients aged ≥70 years. METHODS This is a cross-sectional study of patients aged ≥70 years hospitalised due to a trauma-related injury. Cognitive impairment was defined as a Mini-Mental State Examination (MMSE) score ≤24 points. Medications were coded according to the Anatomical Therapeutic Chemical classification. Three exposures were examined: polypharmacy (≥5 medications), excessive polypharmacy (≥10 medications), and number of medications. Separate logistic regression models adjusted for age, sex, body mass index (BMI), education, smoking, independent living, frailty, multimorbidity, depression, and type of trauma were used to test the association between the three exposures and cognitive impairment. RESULTS A total of 198 patients were included (mean age 80.2; 64.7% women and 35.4% men), of which 148 (74.8%) had polypharmacy and 63 (31.8%) had excessive polypharmacy. The prevalence of cognitive impairment was 34.3% overall, 37.2% in the polypharmacy group and 50.8% in the excessive polypharmacy group. More than 80% of participants were taking at least one analgesic. Overall, polypharmacy was not statistically significantly associated with cognitive impairment (odds ratio (OR) 1.20 [95% confidence interval (CI) 0.46 to 3.11]). However, patients in the excessive polypharmacy group were more than two times more likely to have cognitive impairment (OR 2.88 [95% CI 1.31 to 6.37]) even after adjustments for relevant confounders. Similarly, the number of medications was associated with greater odds of cognitive impairment (OR 1.15 [95% CI 1.04 to 1.28]) after adjustments for the same relevant confounders. CONCLUSION Cognitive impairment is common among older trauma patients, particularly among those in the excessive polypharmacy group. Polypharmacy was not associated with cognitive impairment. Excessive polypharmacy and number of medications, on the other hand, were associated with greater odds of cognitive impairment in older trauma patients.
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Affiliation(s)
- Caroline de Godoi Rezende Costa Molino
- Center on Aging and Mobility, University Hospital Zurich, City Hospital Zurich, Waid and University of Zurich, Zurich, Switzerland
- Department of Aging Medicine and Aging Research, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Lisa Rübel
- Center on Aging and Mobility, University Hospital Zurich, City Hospital Zurich, Waid and University of Zurich, Zurich, Switzerland
| | - Noemi Mantegazza
- Center on Aging and Mobility, University Hospital Zurich, City Hospital Zurich, Waid and University of Zurich, Zurich, Switzerland
- Department of Aging Medicine and Aging Research, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Heike A Bischoff-Ferrari
- Center on Aging and Mobility, University Hospital Zurich, City Hospital Zurich, Waid and University of Zurich, Zurich, Switzerland
- Department of Aging Medicine and Aging Research, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- University Clinic for Aging Medicine, City Hospital, Zurich, Waid, Zurich, Switzerland
| | - Gregor Freystaetter
- Center on Aging and Mobility, University Hospital Zurich, City Hospital Zurich, Waid and University of Zurich, Zurich, Switzerland
- Department of Aging Medicine and Aging Research, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- University Clinic for Aging Medicine, City Hospital, Zurich, Waid, Zurich, Switzerland
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Stuck AK, Basile G, Freystaetter G, de Godoi Rezende Costa Molino C, Lang W, Bischoff-Ferrari HA. Predictive validity of current sarcopenia definitions (EWGSOP2, SDOC, and AWGS2) for clinical outcomes: A scoping review. J Cachexia Sarcopenia Muscle 2023; 14:71-83. [PMID: 36564353 PMCID: PMC9891988 DOI: 10.1002/jcsm.13161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 11/25/2022] [Indexed: 12/25/2022] Open
Abstract
Over the last 3 years new definitions of sarcopenia by the Sarcopenia Definition and Outcome Consortium (2020, SDOC), European Working Group on Sarcopenia in Older People (2019, EWGSOP2) and Asian Working Group on Sarcopenia (2019, AWGS2) have been proposed. The objective of this scoping review was to explore predictive validity of these current sarcopenia definitions for clinical outcomes. We followed the PRISMA checklist for scoping reviews. Based on a systematic search performed by two independent reviewers of databases (Pubmed and Embase) articles comparing predictive validity of two or more sarcopenia definitions on prospective clinical outcomes published since January 2019 (the year these definitions were introduced) were included. Data were extracted and results collated by clinical outcomes and by sarcopenia definitions, respectively. Of 4493 articles screened, 11 studies (mean age of participants 77.6 (SD 5.7) years and 50.0% female) comprising 82 validity tests were included. Overall, validity tests on the following categories of clinical outcomes were performed: fracture (n = 40, assessed in one study), mortality (n = 18), function (n = 11), institutionalization (n = 7), falls (n = 4), and hospitalization (n = 2). Thereby, EWGSOP2 was investigated in 15 validity tests (18.3%) on all categories of clinical outcomes, whereas SDOC was investigated in four validity tests (4.9%) in one study on fractures in men only, and none of the validity tests investigated predictive validity by the AWGS2. However, we were not able to pool the data using a meta-analytic approach due to important methodological heterogeneity between the studies. We identified various definitions of clinical outcomes that were used to test predictive validity of sarcopenia definitions suggesting that an agreement on an operational definition of a clinical outcome is key to advance in the field of sarcopenia. Moreover, data on predictive validity using the sarcopenia definitions by the SDOC and AWGS2 are still scarce and lacking, respectively. In a next step, prospective studies including both women and men are needed to compare predictive validity of current sarcopenia definitions on defined key clinical outcomes.
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Affiliation(s)
- Anna K Stuck
- Centre on Aging and Mobility, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Giacomo Basile
- Centre on Aging and Mobility, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Gregor Freystaetter
- Centre on Aging and Mobility, University Hospital Zurich and University of Zurich, Zurich, Switzerland.,Department of Aging Medicine, University Hospital Zurich, Zurich, Switzerland
| | | | - Wei Lang
- Centre on Aging and Mobility, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Heike A Bischoff-Ferrari
- Centre on Aging and Mobility, University Hospital Zurich and University of Zurich, Zurich, Switzerland.,Department of Aging Medicine, University Hospital Zurich, Zurich, Switzerland.,University Clinic for Aging Medicine, City Hospital Zurich - Waid, Zurich, Switzerland
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Stuck AK, Tsai LT, Freystaetter G, Vellas B, Kanis JA, Rizzoli R, Kressig KS, Armbrecht G, Da Silva JAP, Dawson-Hughes B, Egli A, Bischoff-Ferrari HA. Comparing Prevalence of Sarcopenia Using Twelve Sarcopenia Definitions in a Large Multinational European Population of Community-Dwelling Older Adults. J Nutr Health Aging 2023; 27:205-212. [PMID: 36973929 DOI: 10.1007/s12603-023-1888-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
OBJECTIVES Multinational prevalence data on sarcopenia among generally healthy older adults is limited. The aim of the study was to assess prevalence of sarcopenia in the DO-HEALTH European trial based on twelve current sarcopenia definitions. SETTING AND PARTICIPANTS This is an analysis of the DO-HEALTH study including 1495 of 2157 community-dwelling participants age 70+ years from Germany, France, Portugal, and Switzerland with complete measurements of the sarcopenia toolbox including muscle mass by DXA, grip strength, and gait speed. MEASUREMENTS The twelve sarcopenia definitions applied were Asian Working Group on Sarcopenia (AWGS1), AWGS2, Baumgartner, Delmonico, European Working Group on Sarcopenia in Older People (EWGSOP1), EWGSOP2, EWGSOP2-lower extremities, Foundation for the National Institutes of Health (FNIH1), FNIH2, International Working Group on Sarcopenia in Older People (IWGS), Morley, and Sarcopenia Definitions and Outcomes Consortium (SDOC). RESULTS Mean age was 74.9 years (SD 4.4); 63.3% were women. Sarcopenia prevalence ranged between 0.7% using the EWGSOP2 or AWGS2 definition, up to 16.8% using the Delmonico definition. Overall, most sarcopenia definitions, including Delmonico (16.8%), Baumgartner (12.8%), FNIH1(10.5%), IWGS (3.6%), EWGSOP1 (3.4%), SDOC (2.0%), Morley (1.3%), and AWGS1 (1.1%) tended to be higher than the prevalence based on EWGSOP2 (0.7%). In contrast, the definitions AWGS2 (0.7%), EWGSOP2-LE (1.1%), FNIH2 (1.0%) - all based on muscle mass and muscle strength - showed similar lower prevalence as EWGSOP2 (0.7%). Moreover, most sarcopenia definitions did not overlap on identifying sarcopenia on an individual participant-level. CONCLUSION In this multinational European trial of community-dwelling older adults we found major discordances of sarcopenia prevalence both on a population- and on a participant- level between various sarcopenia definitions. Our findings suggest that the concept of sarcopenia may need to be rethought to reliably and validly identify people with impaired muscle health.
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Affiliation(s)
- A K Stuck
- Anna K. Stuck, Dr. med., Centre on Aging and Mobility, University Hospital Zurich and University of Zurich, c/o Stadtspital Waid, Tièchestrasse 99, 8037 Zürich
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Gagesch M, Chocano-Bedoya PO, Abderhalden LA, Freystaetter G, Sadlon A, Kanis JA, Kressig RW, Guyonnet S, DaSilva JAP, Felsenberg D, Rizzoli R, Blauth M, Orav EJ, Egli A, Bischoff-Ferrari HA. Prevalence of Physical Frailty: Results from the DO-HEALTH Study. J Frailty Aging 2022; 11:18-25. [PMID: 35122086 DOI: 10.14283/jfa.2021.18] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Frailty is a geriatric syndrome associated with multiple negative health outcomes. However, its prevalence varies by population and instrument used. We investigated frailty and pre-frailty prevalence by 5 instruments in community-dwelling older adults enrolled to a randomized-controlled trial in 5 European countries. METHODS Cross-sectional baseline analysis in 2,144 DO-HEALTH participants recruited from Switzerland, Austria, France, Germany, and Portugal with complete data for frailty. Frailty status was assessed by the Physical Frailty Phenotype [PFP], SOF-Frailty Index [SOF-FI], FRAIL-Scale, SHARE-Frailty Instrument [SHARE-FI], and a modified SHARE-FI, and compared by country, age, and gender. Logistic regression was used to determine relevant factors associated with frailty and pre-frailty. RESULTS Mean age was 74.9 (±4.4) years, 61.6% were women. Based on the PFP, overall frailty and pre-frailty prevalence was 3.0% and 43.0%. By country, frailty prevalence was highest in Portugal (13.7%) and lowest in Austria (0%), and pre-frailty prevalence was highest in Portugal (57.3%) and lowest in Germany (37.1%). By instrument and overall, frailty and pre-frailty prevalence was highest based on SHARE-FI (7.0% / 43.7%) and lowest based on SOF-FI (1.0% / 25.9%). Frailty associated factors were residing in Coimbra (Portugal) [OR 12.0, CI 5.30-27.21], age above 75 years [OR 2.0, CI 1.17-3.45], and female gender [OR 2.8, CI 1.48-5.44]. The same three factors predicted pre-frailty. CONCLUSIONS Among relatively healthy adults age 70 and older enroled to DO-HEALTH, prevalence of frailty and pre-frailty differed significantly by instrument, country, gender, and age. Among instruments, the highest prevalence of frailty and pre-frailty was documented by the SHARE-FI and the lowest by the SOF-FI.
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Affiliation(s)
- M Gagesch
- Michael Gagesch, MD, Department of Geriatrics, University Hospital Zurich, Ramistrasse 100, 8091 Zurich, Switzerland, , https://orcid.org/0000-0003-3089-5768
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Freystaetter G, Fischer K, Orav EJ, Egli A, Theiler R, Münzer T, Felson DT, Bischoff‐Ferrari HA. Total Serum Testosterone and Western Ontario and McMaster Universities Osteoarthritis Index Pain and Function Among Older Men and Women With Severe Knee Osteoarthritis. Arthritis Care Res (Hoboken) 2020; 72:1511-1518. [PMID: 31557423 PMCID: PMC7702066 DOI: 10.1002/acr.24074] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 09/17/2019] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To investigate whether serum total testosterone level is associated with knee pain and function in men and women with severe knee osteoarthritis (OA). METHODS We enrolled 272 adults age ≥60 years (mean ± SD age 70.4 ± 4.4 years, 53% women) who underwent unilateral total knee replacement (TKR) due to severe knee OA. Serum testosterone levels and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and function of the operated and contralateral knee were measured at 6-8 weeks after surgery. At the nonoperated knee, 56% of participants had radiographic knee OA with a Kellgren/Lawrence grade ≥2. Cross-sectional analyses were performed by sex and body mass index (BMI) subgroups, using multivariable regression adjusted for age, physical activity, and BMI. RESULTS At the operated knee, higher testosterone levels were associated with less WOMAC pain in men (B = -0.62, P = 0.046) and women (B = -3.79, P = 0.02), and less WOMAC disability scores in women (B = -3.62, P = 0.02) and obese men (B = -1.99, P = 0.02). At the nonoperated knee, testosterone levels were not associated with WOMAC pain in men or women, but higher testosterone levels were associated with less disability in women (B = -0.95, P = 0.02). Testosterone levels were inconsistently associated with pain and disability in BMI subgroups among men. Only among obese women, testosterone levels were inversely associated with radiographic knee OA (odds ratio = 0.10, P = 0.003). CONCLUSION Higher total testosterone levels were associated with less pain in the operated knee in men and women undergoing TKR and less disability in women. At the nonoperated knee, higher testosterone levels were inconsistently associated with less pain and disability.
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Affiliation(s)
- Gregor Freystaetter
- University Hospital ZurichUniversity of Zurichand City Hospital WaidZurichSwitzerland
| | - Karina Fischer
- University Hospital ZurichUniversity of Zurichand City Hospital WaidZurichSwitzerland
| | | | - Andreas Egli
- University Hospital ZurichUniversity of Zurichand City Hospital WaidZurichSwitzerland
| | - Robert Theiler
- University Hospital ZurichUniversity of Zurichand City Hospital WaidZurichSwitzerland
| | - Thomas Münzer
- University Hospital ZurichUniversity of Zurichand City Hospital Waid, Zurich, and Geriatrische KlinikSt. GallenSwitzerland
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Schietzel S, Fischer K, Brugger P, Orav EJ, Renerts K, Gagesch M, Freystaetter G, Stähelin HB, Egli A, Bischoff-Ferrari HA. Effect of 2000 IU compared with 800 IU vitamin D on cognitive performance among adults age 60 years and older: a randomized controlled trial. Am J Clin Nutr 2019; 110:246-253. [PMID: 31152541 DOI: 10.1093/ajcn/nqz081] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 04/11/2019] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Findings on the effects of vitamin D on cognitive performance have been inconsistent and no clinical trials with detailed cognitive testing in healthy older adults have been reported. OBJECTIVES We tested whether 2000 IU is superior to 800 IU vitamin D3/d for cognitive performance among relatively healthy older adults. DESIGN We analyzed data on cognitive performance as the secondary outcome of a 2-y double-blind randomized controlled trial that originally investigated the effect of vitamin D3 on knee function and pain in seniors with osteoarthritis. Participants were randomly assigned to either 2000 or 800 IU vitamin D3/d. Capsules had identical appearances and taste. A total of 273 community-dwelling older adults aged ≥60 y were enrolled 6-8 wk after unilateral joint replacement. Inclusion required a baseline Mini Mental State Examination (MMSE) score of 24. We implemented a detailed 2-h cognitive test battery. The primary cognitive endpoint was the score achieved in the MMSE. Secondary endpoints included a composite score of 7 executive function tests, auditory verbal and visual design learning tests, and reaction times. RESULTS At baseline, mean age was 70.3 y, 31.4% were vitamin D-deficient [25(OH)D <20 ng/mL], and mean ± SD MMSE score was 28.0 ± 1.5. Although the mean ± SD 25(OH)D concentrations achieved differed significantly between treatment groups at 24-mo follow-up (2000 IU = 45.1 ± 10.2 ng/mL; 800 IU = 37.5 ± 8.8 ng/mL; P < 0.0001), none of the primary or secondary endpoints of cognitive performance differed between treatment group. Results by treatment were similar for predefined subgroups of baseline 25(OH)D status (deficient compared with replete) and age (60-69 y compared with ≥70 y). CONCLUSIONS Our study does not support a superior cognitive benefit of 2000 IU compared with 800 IU vitamin D/d among relatively healthy older adults over a 24-mo treatment period. This trial was registered at clinicaltrials.gov as NCT00599807.
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Affiliation(s)
- Simeon Schietzel
- Departments of 1Geriatrics.,Centre on Aging and Mobility, University Hospital Zurich, Waid City Hospital, and University of Zurich, Zurich, Switzerland
| | - Karina Fischer
- Departments of 1Geriatrics.,Centre on Aging and Mobility, University Hospital Zurich, Waid City Hospital, and University of Zurich, Zurich, Switzerland
| | - Peter Brugger
- Neurology, University Hospital Zurich, Zurich, Switzerland
| | - Endel John Orav
- Department of Biostatistics, Harvard School of Public Health, Boston, MA
| | - Klavs Renerts
- Departments of 1Geriatrics.,Centre on Aging and Mobility, University Hospital Zurich, Waid City Hospital, and University of Zurich, Zurich, Switzerland
| | - Michael Gagesch
- Departments of 1Geriatrics.,Centre on Aging and Mobility, University Hospital Zurich, Waid City Hospital, and University of Zurich, Zurich, Switzerland
| | - Gregor Freystaetter
- Departments of 1Geriatrics.,Centre on Aging and Mobility, University Hospital Zurich, Waid City Hospital, and University of Zurich, Zurich, Switzerland
| | | | - Andreas Egli
- Centre on Aging and Mobility, University Hospital Zurich, Waid City Hospital, and University of Zurich, Zurich, Switzerland
| | - Heike Annette Bischoff-Ferrari
- Departments of 1Geriatrics.,Centre on Aging and Mobility, University Hospital Zurich, Waid City Hospital, and University of Zurich, Zurich, Switzerland.,University Clinic for Acute Geriatric Care, Waid City Hospital, Zurich, Switzerland
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10
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Schlögl M, Chocano-Bedoya P, Dawson-Hughes B, Orav EJ, Freystaetter G, Theiler R, Kressig RW, Egli A, Bischoff-Ferrari HA. Effect of Monthly Vitamin D on Chronic Pain Among Community-Dwelling Seniors: A Randomized, Double-Blind Controlled Trial. J Am Med Dir Assoc 2018; 20:356-361. [PMID: 30401610 DOI: 10.1016/j.jamda.2018.09.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 08/27/2018] [Accepted: 09/04/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVE With advancing age, the prevalence of vitamin D deficiency and musculoskeletal pain increases. However, published data on the effectiveness of vitamin D supplementation in reducing chronic pain are inconclusive. The purpose of this study was to test the effect of 3 different monthly doses of vitamin D on chronic pain in seniors 70 years and older with a prior fall event. DESIGN 1-year, double-blind randomized clinical trial. SETTING The trial was conducted in Zurich, Switzerland. Participants were 200 community-dwelling men and women 70 years and older with a prior fall. INTERVENTION Three study groups with monthly treatments were randomized to either a low-dose control group of vitamin D (24,000 IU vitamin D3/mo), a high dose of vitamin D3 (60,000 IU vitamin D3/mo), or a combination of calcifediol and vitamin D3 (24,000 IU vitamin D3 plus 300 μg calcifediol/mo). MEASUREMENTS The primary endpoint was the change in the mean number of painful areas using the McGill Pain map over 12 months of follow-up. All analyses were adjusted for age, sex, body mass index, 25-hydroxyvitamin (OH)D3 levels, and pain scores at baseline. A predefined subgroup analysis was performed by baseline 25(OH)D status (<20 vs ≥ 20 ng/mL). RESULTS The mean age of the participants was 78 years, 67.0% (134 of 200) were female, and 58.0% (116 of 200) were vitamin D deficient (<20 ng/mL) at baseline. Over 12 months of follow-up, the changes in the mean number of painful areas did not differ significantly among treatment groups (P = .46). However, there was a significant interaction effect between baseline vitamin levels (<20 vs ≥ 20 ng/mL) and treatment (P = .02). Among those who were vitamin D replete at baseline (n = 84), there was a significant difference between treatment groups over time (P = .04), and only seniors in the 24,000-IU vitamin D3 group had a marginally significant decrease in their total mean pain score (-0.77; 95% CI, -1.56 to 0.01, P = .05), whereas there were no changes in the high-dose groups. Among seniors who were vitamin D deficient at baseline (n = 116), chronic pain did not differ by treatment groups over time (P = .33). CONCLUSION Our results suggest that both starting level of 25(OH)D3 and monthly treatment dose of vitamin D may be important with respect to chronic pain reduction-with the only benefit seen among vitamin D-replete seniors treated with a monthly dose of 24,000 IU vitamin D3.
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Affiliation(s)
- Mathias Schlögl
- Department of Geriatrics and Aging Research, University Hospital Zurich and University of Zurich, Switzerland; Centre on Aging and Mobility, University of Zurich, Switzerland
| | - Patricia Chocano-Bedoya
- Department of Geriatrics and Aging Research, University Hospital Zurich and University of Zurich, Switzerland; Centre on Aging and Mobility, University of Zurich, Switzerland
| | - Bess Dawson-Hughes
- USDA Human Nutrition Research Center on Aging, Tufts University, Boston, MA
| | - Endel J Orav
- Department of Biostatistics, Harvard School of Public Health, Boston, MA
| | - Gregor Freystaetter
- Department of Geriatrics and Aging Research, University Hospital Zurich and University of Zurich, Switzerland; Centre on Aging and Mobility, University of Zurich, Switzerland
| | - Robert Theiler
- Department of Geriatrics and Aging Research, University Hospital Zurich and University of Zurich, Switzerland; Centre on Aging and Mobility, University of Zurich, Switzerland
| | - Reto W Kressig
- Department of Geriatrics, University of Basel, Basel, Switzerland
| | - Andreas Egli
- Department of Geriatrics and Aging Research, University Hospital Zurich and University of Zurich, Switzerland; Centre on Aging and Mobility, University of Zurich, Switzerland
| | - Heike A Bischoff-Ferrari
- Department of Geriatrics and Aging Research, University Hospital Zurich and University of Zurich, Switzerland; Centre on Aging and Mobility, University of Zurich, Switzerland; University Clinic for Acute Geriatrics Care, Waid City Hospital, Zurich, Switzerland.
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11
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Teister CJ, Chocano-Bedoya PO, Orav EJ, Dawson-Hughes B, Meyer U, Meyer OW, Freystaetter G, Gagesch M, Rizzoli R, Egli A, Theiler R, Kanis JA, Bischoff-Ferrari HA. Which Method of Fall Ascertainment Captures the Most Falls in Prefrail and Frail Seniors? Am J Epidemiol 2018; 187:2243-2251. [PMID: 29912266 DOI: 10.1093/aje/kwy113] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 05/23/2018] [Indexed: 01/14/2023] Open
Abstract
There is no consensus on the most reliable method of ascertaining falls among the elderly. Therefore, we investigated which method captured the most falls among prefrail and frail seniors from 2 randomized controlled trials conducted in Zurich, Switzerland: an 18-month trial (2009-2010) including 200 community-dwelling prefrail seniors with a prior fall and a 12-month trial (2005-2008) including 173 frail seniors with acute hip fracture. Both trials included the same methods of fall ascertainment: monthly active asking, daily self-report diary entries, and a call-in hotline. We compared numbers of falls reported and estimated overall and positive percent agreement between methods. Prefrail seniors reported 499 falls (fall rate = 2.5/year) and frail seniors reported 205 falls (fall rate = 1.4/year). Most falls (81% of falls in prefrail seniors and 78% in frail seniors) were reported via active asking. Among prefrail seniors, diaries captured an additional 19% of falls, while the hotline added none. Among frail seniors, the hotline added 16% of falls, while diaries added 6%. The positive percent agreement between active asking and diary entries was 100% among prefrail seniors and 88% among frail seniors. While monthly active asking captures most falls in both groups, this method alone missed 19% of falls in prefrail seniors and 22% in frail seniors. Thus, a combination of active asking and diaries for prefrail seniors and a combination of active asking and a hotline for frail seniors is warranted.
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Affiliation(s)
- Corina J Teister
- Centre on Aging and Mobility, University Hospital Zurich and City Hospital Waid, Zurich, Switzerland
- Department of Geriatrics and Ageing Research, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Patricia O Chocano-Bedoya
- Centre on Aging and Mobility, University Hospital Zurich and City Hospital Waid, Zurich, Switzerland
- Department of Geriatrics and Ageing Research, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Endel J Orav
- Division of General Medicine, Harvard Medical School and Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts
| | - Bess Dawson-Hughes
- Bone Metabolism Laboratory, Jean Mayer USDA Human Nutrition Research Center on Aging, Boston, Massachusetts
| | - Ursina Meyer
- Centre on Aging and Mobility, University Hospital Zurich and City Hospital Waid, Zurich, Switzerland
- Department of Geriatrics and Ageing Research, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Otto W Meyer
- Centre on Aging and Mobility, University Hospital Zurich and City Hospital Waid, Zurich, Switzerland
- Department of Geriatrics and Ageing Research, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Gregor Freystaetter
- Centre on Aging and Mobility, University Hospital Zurich and City Hospital Waid, Zurich, Switzerland
- Department of Geriatrics and Ageing Research, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Michael Gagesch
- Centre on Aging and Mobility, University Hospital Zurich and City Hospital Waid, Zurich, Switzerland
- Department of Geriatrics and Ageing Research, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Rene Rizzoli
- Bone Disease Service, University Hospitals of Geneva, Geneva, Switzerland
| | - Andreas Egli
- Centre on Aging and Mobility, University Hospital Zurich and City Hospital Waid, Zurich, Switzerland
- Department of Geriatrics and Ageing Research, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Robert Theiler
- Centre on Aging and Mobility, University Hospital Zurich and City Hospital Waid, Zurich, Switzerland
- Department of Geriatrics and Ageing Research, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - John A Kanis
- Institute of Health and Ageing, Catholic University of Australia, Melbourne, Victoria, Australia
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, United Kingdom
| | - Heike A Bischoff-Ferrari
- Centre on Aging and Mobility, University Hospital Zurich and City Hospital Waid, Zurich, Switzerland
- Department of Geriatrics and Ageing Research, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- University Clinic for Acute Geriatric Care, City Hospital Waid, Zurich, Switzerland
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Bischoff-Ferrari HA, Orav EJ, Egli A, Dawson-Hughes B, Fischer K, Staehelin HB, Rizzoli R, Hodler J, von Eckardstein A, Freystaetter G, Meyer U, Guggi T, Burckhardt P, Schietzel S, Chocano-Bedoya P, Theiler R, Willett WC, Felson D. Recovery after unilateral knee replacement due to severe osteoarthritis and progression in the contralateral knee: a randomised clinical trial comparing daily 2000 IU versus 800 IU vitamin D. RMD Open 2018; 4:e000678. [PMID: 30018805 PMCID: PMC6045766 DOI: 10.1136/rmdopen-2018-000678] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 06/10/2018] [Indexed: 01/24/2023] Open
Abstract
Objective To test whether daily high-dose vitamin D improves recovery after unilateral total knee replacement. Methods Data come from a 24-month randomised, double-blind clinical trial. Adults aged 60 and older undergoing unilateral joint replacement due to severe knee osteoarthritis were 6-8 weeks after surgery randomly assigned to receive daily high-dose (2000 IU) or standard-dose (800 IU) vitamin D3. The primary endpoints were symptoms (Western Ontario and McMaster Universities Arthritis Index pain and function scores) assessed at baseline, 6, 12, 18 and 24 months in both knees, and the rate of falls over 24 months. The secondary outcomes were sit-to-stand performance, gait speed, physical activity and radiographic progression in the contralateral knee. Results We recruited 273 participants, 137 were randomised to receive 2000 IU and 136 were randomised to receive 800 IU vitamin D per day. 2000 IU vitamin D increased 25-hydroxyvitamin D levels to 45.6 ng/mL and 800 IU vitamin D to 37.1 ng/mL at month 24 (p<0.0001). While symptoms improved significantly in the operated knee and remained stable in the contralateral knee over time, none of the primary or secondary endpoints differed by treatment group over time. The rate of falls over 24 months was 1.05 with 2000 IU and 1.07 with 800 IU (p=0.84). 30.5% of participants in the 2000 IU and 31.3% of participants in the 800 IU group had radiographic progression in the contralateral knee over 24 months (p=0.88). Conclusions Our findings suggest that a 24-month treatment with daily 2000 IU vitamin D did not show greater benefits or harm than a daily standard dose of 800 IU among older adults undergoing unilateral total knee replacement.
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Affiliation(s)
- Heike A Bischoff-Ferrari
- Department of Geriatrics and Aging Research, University Hospital Zurich, University of Zurich, Zurich, Switzerland.,Center on Aging and Mobility, University of Zurich, Zurich, Switzerland.,University Clinic for Acute Geriatric Care, City Hospital Waid, Zurich, Switzerland
| | - E John Orav
- Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts, USA
| | - Andreas Egli
- Department of Geriatrics and Aging Research, University Hospital Zurich, University of Zurich, Zurich, Switzerland.,Center on Aging and Mobility, University of Zurich, Zurich, Switzerland
| | - Bess Dawson-Hughes
- Jean Mayer USDA Human Nutrition Research Center on Aging, Tufts University, Boston, Massachusetts, USA
| | - Karina Fischer
- Center on Aging and Mobility, University of Zurich, Zurich, Switzerland
| | | | - Rene Rizzoli
- Division of Bone Diseases, Geneva University Hospitals, Geneva, Switzerland
| | - Juerg Hodler
- Institute of Radiology, University Hospital Zurich, Zurich, Switzerland
| | | | - Gregor Freystaetter
- Department of Geriatrics and Aging Research, University Hospital Zurich, University of Zurich, Zurich, Switzerland.,Center on Aging and Mobility, University of Zurich, Zurich, Switzerland
| | - Ursina Meyer
- Department of Geriatrics and Aging Research, University Hospital Zurich, University of Zurich, Zurich, Switzerland.,Center on Aging and Mobility, University of Zurich, Zurich, Switzerland
| | - Thomas Guggi
- Department of Orthopaedic Surgery, Schulthess Clinic, Zurich, Switzerland
| | | | - Simeon Schietzel
- Department of Geriatrics and Aging Research, University Hospital Zurich, University of Zurich, Zurich, Switzerland.,Center on Aging and Mobility, University of Zurich, Zurich, Switzerland
| | - Patricia Chocano-Bedoya
- Department of Geriatrics and Aging Research, University Hospital Zurich, University of Zurich, Zurich, Switzerland.,Center on Aging and Mobility, University of Zurich, Zurich, Switzerland
| | - Robert Theiler
- Department of Geriatrics and Aging Research, University Hospital Zurich, University of Zurich, Zurich, Switzerland.,Center on Aging and Mobility, University of Zurich, Zurich, Switzerland
| | - Walter C Willett
- Department of Nutrition, Harvard School of Public Health, Boston, Massachusetts, USA
| | - David Felson
- Clinical Epidemiology Research and Training Unit, Boston University, Boston, Massachusetts, USA
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