Effects of different exercise intensity on bone mineral density in adults: a comparative systematic review and meta-analysis.

PURPOSE: The primary objective of the present systematic review and meta-analysis was to determine the effect of differing exercise intensity on (areal) bone mineral density (BMD) at lumbar spine and hip in adults by a comparative meta-analysis. METHODS: A systematic review of the literature according to the PRISMA statement included: (a) exercise trials, (b) with ≥two study arms that compared different exercise intensities, (c) intervention ≥6 months, (d) BMD assessments at lumbar spine (LS) or hip. Five electronic databases were scanned without language restrictions up to July 2021. The present analysis of exercise intensity was conducted as a mixed-effect meta-analysis and applied "type of exercise" and "study duration" as moderator in subgroup analyses. Outcome measures were standardized mean differences (SMD) for BMD changes at the LS, and hip. RESULTS: Eleven exercise studies with 26 study arms were included. Although the effect of high-intensity exercise was more pronounced on LS-BMD (SMD: 0.19, 95%-CI: 0.61 to -0.23) and hip-ROI (0.17, 0.38 to -0.04), we did not observe significant differences between the groups (LS-BMD: p=0.373 and hip-BMD: p=0.109). We observed a substantial level of heterogeneity between the trials for LS- but not for hip-BMD. Applying "type of exercise" and "study duration" as moderators did not significantly modify the differences between low and high exercise intensity on BMD at LS or hip. CONCLUSION: There is insufficient evidence for a superior effect of high-intensity exercise on areal BMD at lumbar spine and hip in people aged 50 years and older. Varying exercise intensity with periods of lower exercise intensity intermitted by higher intensity might be a promising option to address the issue of exercise intensities in intervention studies.

Effects of an individualised nutritional intervention to tackle malnutrition in nursing homes: a pre-post study.

PURPOSE: Individualised interventions are recommended to tackle malnutrition in older adults, but approaches for nursing home (NH) residents are scarce. This study investigated the effects of an individualised nutritional intervention in NH residents with (risk of) malnutrition. METHODS: In a pre-post study, 6 weeks (w) of usual care were followed by 6w of intervention. The intervention consisted of up to three supplement modules (sweet and savoury protein creams and protein-energy drink, single or combined) and, if required, reshaped texture-modified meals (RTMM). RESULTS: Fifty residents completed the study (84 ± 8 years, 74% female). One-third (32%) received RTMM. Additional 258 ± 167 kcal/day and 23 ± 15 g protein/day were offered. Mean daily energy intake increased by 207 (95%CI 47-368, p = 0.005) kcal and protein intake by 14 (7-21, p < 0.001) g (w12 vs w1). Quality of life (QoL) increased in the subscale "care relationship" (+ 9 (3-15) points, p = 0.002, w12 vs w6). Body weight, handgrip strength, and other QoL subscales did not change. CONCLUSION: Our intervention improved dietary intake and one QoL subscale in NH residents with (risk of) malnutrition. As a next step, randomized controlled trials are needed to investigate the impact of individualised interventions more comprehensively.

[Less can be more-Examples on medication in older and geriatric patients from current studies]. / Weniger kann mehr sein ­ Beispiele zur Medikation bei älteren und geriatrischen Patienten aus aktuellen Studien.

Polypharmacy, i.e. the prescription of five or more different drugs for medicinal treatment, is a typical problem in older and geriatric patients. Polypharmacy predisposes to different negative health sequelae, such as undesired side effects, drug interactions, potentially inappropriate medication, reduced functional abilities, increased hospitalization and increased mortality. Various consensus groups and specialist societies have developed recommendations on how to handle polypharmacy in geriatric patients. Although concepts to reduce the number of drugs are considered necessary, in many areas there is a lack of evidence on how to limit polypharmacy in geriatric patients and to reduce and discontinue medication. This article presents examples of recent studies dealing with potentially inappropriate medication, vitamin D substitution and antipsychotic drugs, which show how to critically appraise a prescribed medication, to critically check the indications for drugs and to discontinue drug use.

Nutritional status according to the mini nutritional assessment (MNA)® as potential prognostic factor for health and treatment outcomes in patients with cancer - a systematic review.

BACKGROUND: Patients with cancer have an increased risk of malnutrition which is associated with poor outcome. The Mini Nutritional Assessment (MNA®) is often used in older patients with cancer but its relation to outcome is not known. METHODS: Four databases were systematically searched for studies relating MNA-results with any reported outcome. Two reviewers screened titles/abstracts and full-texts, extracted data and rated the risk of bias (RoB) independently. RESULTS: We included 56 studies which varied widely in patient and study characteristics. In multivariable analyses, (risk of) malnutrition assessed by MNA significantly predicts a higher chance for mortality/poor overall survival (22/27 studies), shorter progression-free survival/time to progression (3/5 studies), treatment maintenance (5/8 studies) and (health-related) quality of life (2/2 studies), but not treatment toxicity/complications (1/7 studies) or functional status/decline in (1/3 studies). For other outcomes - length of hospital stay (2 studies), falls, fatigue and unplanned (hospital) admissions (1 study each) - no adjusted results were reported. RoB was rated as moderate to high. CONCLUSIONS: MNA®-result predicts mortality/survival, cancer progression, treatment maintenance and (health-related) quality of life and did not predict adverse treatment outcomes and functional status/ decline in patients with cancer. For other outcomes results are less clear. The moderate to high RoB calls for studies with better control of potential confounders.

Are Health Behaviors and Self-Rated Health Related to Cardiovascular Health and Functional Performance? Results from the Lookup 7+ Cross-Sectional Survey among Persons Aged 65+.

OBJECTIVES: Cardiovascular health (CVH) and physical performance (PP) are key factors of successful ageing. This study investigated whether self-reported CVH behaviours and self-rated health (SRH) are related to ideal CVH and PP. DESIGN: Cross-sectional survey. SETTING: Public places in Italy (e.g. exhibitions, malls, health promotion campaigns), outside of conventional healthcare settings. PARTICIPANTS: 1415 community-living persons aged 65+ years (mean age 72.2 ± 5.4; 58.4% female). MEASUREMENTS: Three ideal CVH behaviors [regular physical activity (PA), healthy diet, no smoking] and SRH (1 excellent - 4 poor) were assessed through a brief questionnaire. Four ideal CVH factors [iBMI ≤ 25 kg/m2, untreated random total blood cholesterol ≤200 mg/dl, absence of diabetes (untreated random blood glucose ≤200 mg/dl), untreated blood pressure (iBP) <140/90mmHg] and two ideal PP factors [grip strength (iGrip), 5-repetition chair-stand test <10 seconds (iStand)] were measured. RESULTS: Adjusted for age and gender, regular PA was positively related to CVH factor score (ß = 0.1; p = < .001), iBMI (OR = 1.8; 95% CI = 1.5-2.3), iBP (OR = 1.3; 95% CI = 1.1-1.6) and iStand (OR = 1.6; 95% CI = 1.3-2.1). Healthy diet was positively related to CVH factor score (ß = 0.1; p = < .05) and iGrip (OR = 1.4; 95% CI = 1.1-1.8). Participants rating SRH as "good" (OR = 2.0; 95% CI = 1.1-3.9) and "not so good" (OR = 2.3; 95% CI = 1.2-4.5) met iDiabetes more often than those with poor SRH. Moreover, iStand (OR = 3.2; 95% CI = 1.6-6.6) and iGrip (OR = 4.2; 95% = CI 2.0-8.8) were more prevalent among participants with excellent SRH compared with those with poor SRH. CONCLUSIONS: Physical activity, diet and self-rated health may provide quick and easy-to-assess metrics to identify persons aged 65+ years at risk of cardiovascular events and functional impairment, who could particularly benefit from engaging in health promotion programs.

[Diagnosis and therapy of sarcopenia-an update]. / Update zur Diagnose und Therapie der Sarkopenie.

Since 2016 sarcopenia, the age-associated loss of muscle mass, strength and function, has the ICD-10-GM code M62.50 (International Statistical Classification of Diseases and Related Health Problems, 10th Revision, German Modification). The diagnosis of sarcopenia requires the combined presence of low muscle strength and low muscle mass. Well-established approaches for the prevention and therapy of sarcopenia are exercise programs-in particular strength, endurance and power training-and nutritional interventions, preferably a combination of both. Adequate protein intake is considered highly relevant, while the role of other nutrients involved in muscle metabolism (e. g. creatine, vitamin D, antioxidants, omega-3 fatty acids) is less clear, being still the subject of controversial discussions. Innovative pharmacological therapies are currently under investigation and their future relevance for this indication is unclear. In general, it has to be stated that there are still only few intervention studies available that focused specifically on sarcopenia in older individuals. More studies in this rapidly increasing population are urgently needed.

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

OBJECTIVES: Sarcopenia, defined as an age-associated loss of skeletal muscle function and muscle mass, occurs in approximately 6 - 22 % of older adults. This paper presents evidence-based clinical practice guidelines for screening, diagnosis and management of sarcopenia from the task force of the International Conference on Sarcopenia and Frailty Research (ICSFR). METHODS: To develop the guidelines, we drew upon the best available evidence from two systematic reviews paired with consensus statements by international working groups on sarcopenia. Eight topics were selected for the recommendations: (i) defining sarcopenia; (ii) screening and diagnosis; (iii) physical activity prescription; (iv) protein supplementation; (v) vitamin D supplementation; (vi) anabolic hormone prescription; (vii) medications under development; and (viii) research. The ICSFR task force evaluated the evidence behind each topic including the quality of evidence, the benefit-harm balance of treatment, patient preferences/values, and cost-effectiveness. Recommendations were graded as either strong or conditional (weak) as per the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Consensus was achieved via one face-to-face workshop and a modified Delphi process. RECOMMENDATIONS: We make a conditional recommendation for the use of an internationally accepted measurement tool for the diagnosis of sarcopenia including the EWGSOP and FNIH definitions, and advocate for rapid screening using gait speed or the SARC-F. To treat sarcopenia, we strongly recommend the prescription of resistance-based physical activity, and conditionally recommend protein supplementation/a protein-rich diet. No recommendation is given for Vitamin D supplementation or for anabolic hormone prescription. There is a lack of robust evidence to assess the strength of other treatment options.

Nutritional Intervention in Sarcopenia: Report from the International Conference on Frailty and Sarcopenia Research Task Force.

Research suggests that poor nutrition is an underlying cause of sarcopenia and frailty, and that dietary interventions may prevent or treat age-related loss of muscle mass and strength. In February 2018, the International Conference on Frailty and Sarcopenia Research Task Force explored the current status of research on nutritional interventions for sarcopenia as well as gaps in knowledge, including whether nutritional supplements must be combined with physical activity, and the role of nutritional intervention in sarcopenic obese individuals. The lack of consistency across trials in terms of target populations, assessments, health-care settings, control groups, and choice of outcomes has made it difficult to draw meaningful conclusions from recent studies. The Task Force recommended large randomized controlled trials in heterogeneous, real-world populations to enable sub-group analysis. The field also needs to reach consensus on what outcomes are most meaningful and what represents clinically meaningful change.

[Hospital pastoral care of people with dementia : A qualitative interview study with professional hospital pastoral carers]. / Klinikseelsorge mit Menschen mit Demenz : Eine qualitative Interviewstudie mit professionellen Klinikseelsorgern.

BACKGROUND: Communicating and interacting with persons diagnosed with dementia (PwD) present a challenge to pastoral carers, since most classical pastoral care approaches concentrate on conversation as a medium of relationship formation and do not take limited communication skills into account. This study focuses on the following question: how can hospital-based pastoral carers find appropriate methods of communication and interaction with PwD and provide them with pastoral care? METHODS: A total of 10 professional pastoral carers participated in the study. Each of these persons had extensive experience with PwD. Data were collected with the use of guideline-based interviews. The interviews were evaluated using Mayring's method of qualitative content analysis. RESULTS: One of the main challenges faced by the pastoral carers in interacting with PwD was to explore communication strategies based on non-verbal communication, in addition to verbal communication. Pastoral carers need to find alternative communicative approaches, such as biographical, non-verbal, and physical sense-related methods. Clinical pastoral education did not adequately equip these professionals for communicating and interacting with PwD. The interviewed pastoral carers acquired this specific knowledge through independent research of the academic literature, observation of other professionals, dementia-specific training courses, and practical experience. CONCLUSION: Pastoral carers can make a positive contribution to the holistic care of PwD through their unique communicative and relationship approach to care. It is imperative to develop adequate pastoral care concepts and to integrate methodologies for dealing with PwD into the training curriculum of pastoral carers.

Crystal arthritides - gout and calcium pyrophosphate arthritis : Part 2: clinical features, diagnosis and differential diagnostics.

Gout develops in four stages beginning with an asymptomatic increase in blood levels of uric acid. An acute gout attack is an expression of an underlying inflammatory process, which in the course of time is self-limiting. Without therapy monosodium urate crystals remain in the synovial fluid and synovial membrane and trigger more acute attacks. In the course of the disease monosodium urate crystals form deposits (tophi) leading in severe forms to irreversible joint deformities with loss of functionality. In 20% of cases gout leads to involvement of the kidneys. Overproduction of uric acid can cause nephrolithiasis. These stones can be composed of uric acid or calcium phosphate. Another form of kidney disease caused by gout is uric acid nephropathy. This is a form of abacterial chronic inflammatory response with deposition of sodium urate crystals in the medullary interstitium. Acute obstructive nephropathy is relatively rare and characterized by renal failure due to uric acid precipitation in the tubules because of rapid cell lysis that occurs, for example, with chemotherapy. There is a causal interdependence between the occurrence of hyperuricemia and hypertension. Uric acid activates the renin-angiotensin-aldosterone (RAA) system and inhibits nitric oxide (NO) with the possible consequence of a rise in systemic vascular resistance or arteriolar vasculopathy; however, uric acid is also an apparently independent risk factor for atherosclerosis. In contrast to young patients, the diagnosis of an acute gout attack in the elderly can be a challenge for the physician. Polyarticular manifestations and obscure symptoms can make it difficult to differentiate it from rheumatoid arthritis and calcium pyrophosphate deposition disease (CPPD). Aspiration of synovial fluid with visualization of urate crystals using compensated polarized light microscopy is the gold standard for diagnosis of acute gout. Moreover, analysis of synovial fluid enables a distinction from septic arthritis by Gram staining and bacterial culture. Soft tissue ultrasonography is useful to detect affected synovial tissue and monosodium urate crystals within the synovial fluid. Involvement of bone occurs relatively late in the disease so that x­ray images are not useful in the early stages but might be helpful in differential diagnostics. Dual energy computed tomography (CT) and magnetic resonance imaging (MRI) can be used for certain indications.

Crystal arthritides - gout and calcium pyrophosphate arthritis : Part 1: Epidemiology and pathophysiology.

Gout and calcium pyrophosphate deposition disease (CPPD, pseudogout) are still the most frequent inflammatory arthritides in multimorbid elderly patients. Gout and CPPD are different diseases and based on different pathophysiological principles. Gout is closely associated with the metabolic syndrome and is an independent risk factor for cardiovascular mortality. The prevalence of asymptomatic hyperuricemia is estimated to be 10-20% of adults in industrial nations and prevalence is strongly associated with age. More than 7% of persons aged over 65 years suffer from clinically manifest gout. The underlying pathophysiological principle is an imbalance between the formation and elimination of uric acid. The degradation of the purine bases adenine and guanosine to uric acid is catalysed by xanthine oxidase and genetic polymorphisms and mutations play an important role in absorption and excretion processes. Furthermore, carrier proteins, such as URAT-1 or OAT-4 also have an influence on these processes. An imbalance of the physiological processes results in the solubility product being exceeded, which in consequence leads to crystallization of urate. This induces a cascade of massive inflammatory reactions at the molecular and cellular level with the activation of cytokines. The inflammatory process can be stopped by neutrophil extracellular traps (NETs) that modulate aggregation and degradation of chemokines and cytokines and partitioning of crystallized urate against immune cells. Calcium pyrophosphate dehydrate (CPP) crystals are formed in the cartilage and CPP deposition can be found in 30% of people aged over 80 years. Inorganic pyrophosphate (PPi) is synthesized in chondrocytes and plays an important part in the formation of calcium pyrophosphate crystals. The degradation is catalyzed by inorganic pyrophosphatases. If there is dysregulation of this homeostasis more PPi is produced, which ultimately contributes to the formation of the CPP crystals.

Crystal arthritides - gout and calcium pyrophosphate arthritis : Part 3: Treatment.

The treatment of gout is based on several principles. Symptom control and termination of the inflammatory process are important early goals, whereas the urate level should be lowered in the long term to prevent further gout attacks and complications. The non-pharmacological approach is based on individually informing the patient on dietary measures and changes of life style. Besides physical measures, such as cold applications on the affected joint, various medications are available for treatment of an acute gout attack. The choice of drug depends on the individual risk profile. If non-steroidal anti-inflammatory drugs (NSAID) and coxibs are chosen it should be taken into account that the use is restricted in patients with renal insufficiency. Moreover, these drugs may have gastrointestinal side effects and are associated with increased cardiovascular morbidity and mortality. Colchicine has gastrointestinal side effects at high dosages but can also be used for differential diagnostics if there is a quick response to treatment. Steroids are an effective alternative and can be given orally or parenterally in patients with dysphagia. Moreover, steroids can be used in cases of renal insufficiency. After symptoms of the acute attack have subsided, urate lowering therapy should be initiated to prevent further attacks. Low-dose urate lowering therapy can be started during an acute gout attack when acute therapy is initiated. Allopurinol is still the medication of choice but its use is restricted in patients with renal insufficiency. A rare but serious side effect is allopurinol hypersensitivity syndrome. Febuxostat can be an alternative in patients who do not tolerate allopurinol. In February 2016, lesinurad, an URAT-1 and OAT-4 inhibitor, was approved in combination with allopurinol or febuxostat. Data on the effectiveness and safety of synthetic uricases and biologicals are still sparse for elderly patients. These substances are reserved for severe cases of gout.

[Syncope, falls and vertigo]. / Synkope, Sturz, Schwindel.

Dizziness/vertigo, falls and syncope are among the most common reasons for seeking medical care. As clinical entities they share common pathogenetic and clinical features and differences. The diagnostic work-up can often be initiated in a general practitioner's or internist's practice and, if necessary, completed in an interdisciplinary emergency unit. Simple diagnostic tools can be used in an outpatient setting to obtain valuable diagnostic information. First and foremost, it is important to differentiate between prognostically favorable clinical events and potentially serious disease. In younger patients diagnostic procedures should primarily focus on potential structural cardiac disease and/or primary arrhythmia. The same applies to elderly patients in whom, however, multicausal clinical symptoms and severe complications in the case of falls are characteristic. Elderly patients frequently require the involvement of various clinical specialties to investigate a broad spectrum of potential differential diagnoses in an interdisciplinary diagnostic approach, which is not always available in practice. In the emergency unit, decisions regarding inpatient care need to be made individually. In elderly patients, inpatient care is sometimes necessary not only due to acute disease, but also in order to ensure social care. Geriatric day hospitals may be a suitable option for some of these patients.