Multifaceted Interventions Inclusive of Medication Optimization for Frailty in Aged Care: A Systematic Review.

OBJECTIVES: Implementation of best practice frailty guidelines in residential aged care is currently unclear, and there is a particular scarcity of evidence regarding multifaceted frailty treatments inclusive of medication optimization in these settings, despite the bidirectional relationship between polypharmacy and frailty. This review aimed to retrieve all relevant literature and evaluate the effect of medication optimization delivered in conjunction with exercise and/or nutritional interventions in the best-practice management of frailty in residential aged care. DESIGN: Systematic review with a qualitative synthesis. SETTINGS AND PARTICIPANTS: Older adults residing within residential aged care (otherwise referred to as nursing homes or long-term care). METHODS: The protocol was prospectively registered on PROSPERO (Reg. No.: CRD42022372036) using the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. Five electronic databases were searched from inception to November 23, 2023, with alerts monitored until March 28, 2024. Quality of studies was assessed using the ROB 2 and ROBIN-1 tools. RESULTS: A total of 10,955 articles were retrieved; 62 full articles were reviewed, with 3 studies included (2 randomized controlled trials and 1 nonrandomized controlled trial) involving 1030 participants. Included studies did not use specific frailty scores but reported individual components of frailty such as weight loss or number of medications prescribed. No trial combining medication review, exercise, and nutrition was identified. Medication review reduced the number of medications prescribed, whereas the use of nutritional support reduced gastrointestinal medication and maintained weight. CONCLUSION AND IMPLICATIONS: There is no published research investigating best-practice guidelines for medication optimization used in combination with both exercise and nutrition in aged care to address frailty. This review confirms the need for studies implementing Consensus Guidelines for frailty treatment in this vulnerable cohort.

The Frailty Reduction via Implementation of Exercise, Nutrition, and Deprescribing (FRIEND) Trial: Study Protocol and Recruitment Results.

INTRODUCTION: Virtually all adults in aged care facilities are frail, a condition which contributes to falls, cognitive decline, hospitalisation, and mortality. Polypharmacy, malnutrition, sedentariness, and sarcopenia are risk factors amenable to intervention. The Asia-Pacific Frailty Management Guidelines recommend anabolic exercise and the optimisation of medications and nutrition. However, no study has evaluated this best practice intervention triad in aged care. METHODS: The Frailty Reduction via the Implementation of Exercise, Nutrition, and Deprescribing (FRIEND) Trial (ANZCTR No.ACTRN12622000926730p) is a staged 6-month translational trial evaluating resident outcomes, staff/caregiver knowledge, and institutional implementation in a Townsville aged care facility. Residents received high-intensity resistance exercise and balance training and medication and nutrition optimisation co-implemented by investigators (exercise physiologist, geriatrician, pharmacist, and nutritionist) and facility staff. Staff and caregivers completed comprehensive education modules and training. We report the trial protocol and recruitment results. RESULTS: 29 residents (21 female, age: 88.6 ± 6.3 years) were recruited. At baseline, the residents were frail (frailty scale nursing home (FRAIL-NH); 6.3 ± 2.4/14), cognitively impaired (Montreal Cognitive Assessment; 13.8 ± 6.8/30), functionally impaired (Short Physical Performance Battery; 4.9 ± 3.1/12, 6 min walk distance; 222.2 ± 104.4 m), and were prescribed numerous medications (15.5 ± 5.9). Two residents died and one withdrew before the intervention's commencement. Thirty family members and 19 staff (carers, allied health assistants, nurse managers, registered nurses, lifestyle-leisure officers, kitchen/hospitality staff, and senior leadership) were recruited to receive frailty education modules. CONCLUSIONS: The FRIEND trial is currently being implemented with results expected in mid-2024. This is the first trial to evaluate the implementation of the best practice frailty guidelines including anabolic exercise and medication/nutritional optimisation in residential aged care.

Caring for Informal Dementia Caregivers and Their Loved Ones Via the HOMeCARE Exercise and Mindfulness for Health Program (HOMeCARE): A Randomized, Single-Blind, Controlled Trial.

Objective: To investigate the effects of a dyadic intervention of mindfulness-based stress reduction (MBSR) for informal dementia caregivers and home-based balance and progressive resistance training (PRT) for their loved ones. Methods: The study was a two arm, randomized, controlled, single-blinded, parallel-group trial. Dyads were randomized to an intervention group: an 8-week MBSR course (daily) and an 8-week PRT and balance training (3 days/week) for their loved ones or a waiting list control group. Results: Nine dyads were randomized [caregivers: median age 75 (40-81) years, loved ones: 77 (73-88) years]. The intervention significantly improved caregiver mindfulness [relative effect size (95% confidence interval) 1.35 (-0.10, 2.81); p = .009] and functional mobility in their loved ones [mean difference (95% confidence interval) 1.53 (-3.09, 6.14)] with no significant effects on caregiver burden [relative effect size (95% confidence interval) 0.22 (-1.09, 1.54); p = .622]. Conclusion: The study appeared feasible in the home environment and future large and longer trials should test the efficacy of a more abbreviated MBSR intervention and to optimize adoption and sustain adherence over time. Trial registry name: HOMeCare: Caring for the Dementia Caregiver and their Loved One via the HOMeCare Exercise and Mindfulness for Health Program Trial URL: https://www.australianclinicaltrials.gov.au/anzctr/trial/ACTRN12617000347369 Registration number: ACTRN12617000347369.

Promoting independence in Lewy body dementia through exercise: the PRIDE study.

BACKGROUND: Lewy body dementia (LBD) is an aggressive type of dementia of rapid, fluctuating disease trajectory, higher incidence of adverse events, and poorer functional independence than observed in Alzheimer's disease dementia. Non-pharmacological treatments such as progressive, high-intensity exercise are effective in other neurological cohorts but have been scarcely evaluated in LBD. METHODS: The Promoting Independence in Lewy Body Dementia through Exercise (PRIDE) trial was a non-randomised, non-blinded, crossover pilot trial involving older adults with LBD consisting of a baseline assessment, an 8-week wait-list, and an 8-week exercise intervention. The aims of this study were to evaluate the determinants of the primary outcome functional independence, as measured by the Movement Disorder Society Unified Parkinson's Disease Rating Scale, and the feasibility and preliminary efficacy of an exercise intervention on this outcome. Additionally, important clinical characteristics were evaluated to explore associations and treatment targets. The exercise intervention was supervised, clinic-based, high-intensity progressive resistance training (PRT), challenging balance, and functional exercises, 3 days/week. RESULTS: Nine participants completed the baseline cross-sectional study, of which five had a diagnosis of Parkinson's disease dementia (PDD), and four dementia with Lewy Bodies (DLB). Six completed the exercise intervention (three PDD, three DLB). The cohort was diverse, ranging from mild to severe dementia and living in various residential settings. Greater functional independence at baseline was significantly associated with better physical function, balance, cognition, quality of life, muscle mass ratio, walking endurance, faster walking speed and cadence, and lower dementia severity (p < 0.05). Participants declined by clinically meaningful amounts in functional independence, cognition, physical function, muscle mass, and weight over the wait-list period (p < 0.05). Following exercise, participants improved by clinically meaningful amounts in functional independence, cognition, physical function, and strength (p < 0.05). Progressive, high intensity exercise was well-tolerated (> 80% adherence), and only one minor exercise-related adverse event occurred. CONCLUSIONS: PRIDE is the first exercise trial conducted specifically within individuals diagnosed with LBD, and provides important insight for the design of larger, randomized trials for further evaluation of progressive, high-intensity exercise as a valuable treatment in LBD. TRIAL REGISTRATION: The PRIDE trial protocol has previously been prospectively registered (08/04/2016, ANZCTR: ACTRN12616000466448).

Dermatoscopic features of pigmented intraepidermal carcinoma on the head and neck.

BACKGROUND AND OBJECTIVE: Pigmented intraepidermal carcinoma is characterized by dermatoscopic dots and structureless areas, including dots in linear arrangement and by coiled vessels. There are no studies describing the dermatoscopic features of pigmented intraepidermal carcinoma on the head and neck. We aim to characterize the clinical and dermatoscopic appearance of this entity. PATIENTS AND METHODS: We retrospectively analyzed 79 cases of pigmented intraepidermal carcinoma on the head and neck. RESULTS: Pigmented intraepidermal carcinoma on the head and neck was characterized dermatoscopically by multiple colors (98.7 %, n = 78), pigmented circles (48.1 %, n = 38), white circles (17.7 %, n = 14), angulated lines (41.8 %, n = 33) and structureless areas (86.1 %, n = 68). Dots in linear arrangement were present in 13.9 % (n = 11). Coiled vessels were present in 7.6 % (n = 6), the dominant vessel type being prominent serpentine vessels (29.2 %, n = 23), thicker and/or redder in color than surrounding vessels, most being in the angular arrangement of the dermal plexus (24.1 %, n = 19). CONCLUSIONS: Pigmented intraepidermal carcinoma on the head and neck differs from current published descriptions of pigmented intraepidermal carcinoma, reaching statistical significance with a lower incidence of coiled vessels and a higher incidence of pigmented circles, with evident similarities to pigmented actinic keratosis at that location.

Interrupting the trajectory of frailty in dementia with Lewy bodies with anabolic exercise, dietary intervention and deprescribing of hazardous medications.

An 87-year-old man with dementia with Lewy bodies, living in residential aged care, exhibited rapid functional decline and weight loss associated with injurious falls over 9 months. Independent clinicians (geriatrician and exercise physiologist) assessed him during an extended wait-list period prior to his commencement of a pilot exercise trial. The highly significant role of treatable factors including polypharmacy, sarcopenia and malnutrition as contributors to frailty and rapid functional decline in this patient are described. The results of a targeted intervention of deprescribing, robust exercise and increased caloric intake on his physical and neuropsychological health status are presented. This case highlights the need to aggressively identify and robustly treat reversible contributors to frailty, irrespective of advanced age, progressive 'untreatable' neurodegenerative disease and rapidly deteriorating health in such individuals. Frailty is not a contraindication to robust exercise; it is, in fact, one of the most important reasons to prescribe it.

Promoting independence in Lewy body dementia through exercise (PRIDE) study: Protocol for a pilot study.

BACKGROUND: Lewy Body dementia (LBD) is the second most prevalent neurodegenerative dementia. This form of dementia is notable for an aggressive disease course consisting of a combination of cognitive, Parkinsonian, affective, and physiological symptoms that significantly increase morbidity and mortality, and decrease life expectancy in this population compared to more common dementias. Additionally, those diagnosed with LBD are often excluded from trials evaluating exercise in similar diseases such as Alzheimer's disease or Parkinson's disease due to the complexity and concurrency of motor and cognitive symptoms. Consequently, there is scarce research evaluating the effect of exercise on individuals with LBD. METHODS: The PRomoting Independence in Lewy Body Dementia through Exercise (PRIDE) trial is a novel non-randomised, crossover pilot study consisting of an 8-week wait-list usual care period, followed by an 8-week exercise intervention targeting progressive resistance and balance training. The trial aim is to evaluate the effect of exercise on the primary outcome of functional independence and secondary outcomes including cognitive, physical, psychosocial and quality of life measures in people living with LBD and their caregivers. The intervention involves 3 supervised 1-h sessions per week (24 sessions in total) administered by an Accredited Exercise Physiologist in a clinical facility at the University of Sydney in Lidcombe, Australia. DISCUSSION: The PRIDE study is the first controlled trial to evaluate a robust exercise intervention within a LBD cohort and will provide crucial information required to inform robust future clinical trials. TRIAL REGISTRATION: Australia and New Zealand Trial Register (ANZCTR): ACTRN12616000466448; Key words: Lewy body; dementia; exercise; anabolic; functional independence.

Reliability and validity of a Mediterranean diet and culinary index (MediCul) tool in an older population with mild cognitive impairment.

Dementia is a leading cause of morbidity and mortality without pharmacologic prevention or cure. Mounting evidence suggests that adherence to a Mediterranean dietary pattern may slow cognitive decline, and is important to characterise in at-risk cohorts. Thus, we determined the reliability and validity of the Mediterranean Diet and Culinary Index (MediCul), a new tool, among community-dwelling individuals with mild cognitive impairment (MCI). A total of sixty-eight participants (66 % female) aged 75·9 (sd 6·6) years, from the Study of Mental and Resistance Training study MCI cohort, completed the fifty-item MediCul at two time points, followed by a 3-d food record (FR). MediCul test-retest reliability was assessed using intra-class correlation coefficients (ICC), Bland-Altman plots and κ agreement within seventeen dietary element categories. Validity was assessed against the FR using the Bland-Altman method and nutrient trends across MediCul score tertiles. The mean MediCul score was 54·6/100·0, with few participants reaching thresholds for key Mediterranean foods. MediCul had very good test-retest reliability (ICC=0·93, 95 % CI 0·884, 0·954, P<0·0001) with fair-to-almost-perfect agreement for classifying elements within the same category. Validity was moderate with no systematic bias between methods of measurement, according to the regression coefficient (y=-2·30+0·17x) (95 % CI -0·027, 0·358; P=0·091). MediCul over-estimated the mean FR score by 6 %, with limits of agreement being under- and over-estimated by 11 and 23 %, respectively. Nutrient trends were significantly associated with increased MediCul scoring, consistent with a Mediterranean pattern. MediCul provides reliable and moderately valid information about Mediterranean diet adherence among older individuals with MCI, with potential application in future studies assessing relationships between diet and cognitive function.

Age estimation in older adults: Use of pulp/tooth ratios calculated from tooth sections.

OBJECTIVES: Accurate age estimates are foundational for bioarchaeological research, yet the ability to accurately age older adult skeletons remains elusive. This study uses a new version of pulp/tooth area calculations to investigate chronological age of older archaeological individuals. MATERIALS AND METHODS: Pulp/tooth area ratios were calculated on modern control teeth (n = 10) that were first radiographed and then sectioned for comparative analysis. Pulp/tooth area ratios were determined on sectioned teeth using ImageJ software for: (a) modern individuals of known age (n = 26); (b) individuals from Belleville, Ontario, Canada (1821-1874) with documented age (n = 50); and (c) Belleville individuals with skeletally estimated age (n = 122). RESULTS: Calculations from tooth sections on modern teeth (n = 10) resulted in a mean absolute error (MAE) of ±3.9 years, whereas the radiographic method for the same teeth had an MAE of ±14.45 years. Results indicate that sectioned pulp/tooth area ratios are a significant predictor of chronological age (p < .005), with MAEs of ±4.53 years for Belleville and ±3.77 years for modern individuals. There were no statistically significant differences in age estimations between modern and archaeological individuals, or with respect to tooth type, sex, or intra/inter-observer estimations. DISCUSSION: This study provides a new more accurate method for estimating age-at-death, particularly for individuals in the 50+ age category. Sectioning the teeth and directly measuring exposed pulp chambers results in age estimations that were within ±4.15 years for both modern and archaeological individuals, thus presenting a method that will enhance the ability to age older individuals.

Exercise for Individuals with Lewy Body Dementia: A Systematic Review.

BACKGROUND: Individuals with Lewy body Dementia (LBD), which encompasses both Parkinson disease dementia (PDD) and Dementia with Lewy Bodies (DLB) experience functional decline through Parkinsonism and sedentariness exacerbated by motor, psychiatric and cognitive symptoms. Exercise may improve functional outcomes in Parkinson's disease (PD), and Alzheimer's disease (AD). However, the multi-domain nature of the LBD cluster of symptoms (physical, cognitive, psychiatric, autonomic) results in vulnerable individuals often being excluded from exercise studies evaluating physical function in PD or cognitive function in dementia to avoid confounding results. This review evaluated existing literature reporting the effects of exercise interventions or physical activity (PA) exposure on cluster symptoms in LBD. METHODS: A high-sensitivity search was executed across 19 databases. Full-length articles of any language and quality, published or unpublished, that analysed effects of isolated exercise/physical activity on indicative Dementia with Lewy Bodies or PD-dementia cohorts were evaluated for outcomes inclusive of physical, cognitive, psychiatric, physiological and quality of life measures. The protocol for this review (Reg. #: CRD42015019002) is accessible at http://www.crd.york.ac.uk/PROSPERO/. RESULTS: 111,485 articles were initially retrieved; 288 full articles were reviewed and 89.6% subsequently deemed ineligible due to exclusion of participants with co-existence of dementia and Parkinsonism. Five studies (1 uncontrolled trial, 1 randomized controlled trial and 3 case reports) evaluating 16 participants were included. Interventions were diverse and outcome homogeneity was low. Habitual gait speed outcomes were measured in 13 participants and increased (0.18m/s, 95% CI -0.02, 0.38m/s), exceeding moderate important change (0.14m/s) for PD cohorts. Other outcomes appeared to improve modestly in most participants. DISCUSSION: Scarce research investigating exercise in LBD exists. This review confirms exercise studies in PD and dementia consistently exclude LBD participants. Results in this cohort must be treated with caution until robustly designed, larger studies are commissioned to explore exercise efficacy, feasibility and clinical relevance.