Associations Between Hypertension, Angiotensin-Converting Enzyme Inhibitors, and Physical Performance in Very Old Adults: Results from the ilSIRENTE Study.

BACKGROUND: Results regarding the associations between hypertension-related parameters and physical performance in older adults are conflicting. A possible explanation for these divergent results is that investigations may not have adjusted their analyses according to the use of angiotensin-converting enzyme inhibitors (ACEIs). OBJECTIVES: To examine the associations between hypertension-related parameters, ACEI use, and a set of physical performance tests in very old adults. DESIGN: Cross-sectional study from the ilSIRENTE database. SETTING: Mountain community of the Sirente geographic area (L'Aquila, Abruzzo, Italy). PARTICIPANTS: All persons born in the Sirente area (13 municipalities) before 1 January 1924 and living in that region at the time of study were identified and invited to participate. The final sample included 364 older adults (mean age: 85.8 ± standard deviation [SD] 4.8). MEASUREMENTS: Physical performance was assessed using isometric handgrip strength (IHG), walking speed (WS) at normal and fast pace, 5-time sit-to-stand test (5STS), and muscle power measures. Blood pressure (BP) was measured after 20 to 40 min of rest, while participants sat in an upright position. Drugs were coded according to the Anatomical Therapeutic and Chemical codes. ACEIs were categorized in centrally (ACEI-c) and peripherally (ACEI-p) acting. Blood inflammatory markers, free insulin-like growth factor 1 (IGF-1), and IGF-binding protein 3 (IGFBP-3) were assayed. RESULTS: Results indicated that 5STS test was significantly and negatively associated with diastolic BP values. However, significance was lost when results were adjusted for ACEI use. Participants on ACEIs were more likely to have greater specific muscle power and higher blood levels of IGFBP-3 than non-ACEI users. When participants were categorized according to ACEI subtypes, those on ACEI-p had higher blood IGF-1 levels compared with ACEI-c users. CONCLUSIONS: The main findings of the present study indicate that ACEI use might influence the association between hypertension-related parameters and neuromuscular parameters in very old adults. Such results may possibly be linked to the effects of ACEI-p on the IGF-1 pathway.

Protein Intake from Various Foods Sources Is Negatively Associated with Cardiometabolic Risk Markers in Italian Older Adults.

OBJECTIVES: To examine the relationships between protein intake from various food sources and cardiometabolic risk markers in Italian older adults. DESIGN: Cross-sectional study. SETTING: Unconventional settings across Italy (e.g., exhibitions, health promotion campaigns). PARTICIPANTS: People 65+ years who provided a written informed consent. MEASUREMENTS: Blood pressure (BP), blood glucose, total blood cholesterol, and anthropometric indices were assessed. Daily protein intake was estimated for 12 food items listed in a food frequency questionnaire. RESULTS: Three-thousand four-hundred twenty-four older adults (mean age: 72.7 ± 5.7 years; 55% women) were included in the study. Results of linear regression analysis indicated that protein intake from several food sources was negatively associated with BP, waist and hip circumferences, and waist-to-hip ratio in both sexes. Blood glucose levels were inversely associated with many protein sources in women. Positive associations were observed between some protein sources and total blood cholesterol in both men and women. CONCLUSION: Our findings suggest that dietary protein is differentially associated with cardiometabolic risk factors depending on sex and food sources.

International Exercise Recommendations in Older Adults (ICFSR): Expert Consensus Guidelines.

The human ageing process is universal, ubiquitous and inevitable. Every physiological function is being continuously diminished. There is a range between two distinct phenotypes of ageing, shaped by patterns of living - experiences and behaviours, and in particular by the presence or absence of physical activity (PA) and structured exercise (i.e., a sedentary lifestyle). Ageing and a sedentary lifestyle are associated with declines in muscle function and cardiorespiratory fitness, resulting in an impaired capacity to perform daily activities and maintain independent functioning. However, in the presence of adequate exercise/PA these changes in muscular and aerobic capacity with age are substantially attenuated. Additionally, both structured exercise and overall PA play important roles as preventive strategies for many chronic diseases, including cardiovascular disease, stroke, diabetes, osteoporosis, and obesity; improvement of mobility, mental health, and quality of life; and reduction in mortality, among other benefits. Notably, exercise intervention programmes improve the hallmarks of frailty (low body mass, strength, mobility, PA level, energy) and cognition, thus optimising functional capacity during ageing. In these pathological conditions exercise is used as a therapeutic agent and follows the precepts of identifying the cause of a disease and then using an agent in an evidence-based dose to eliminate or moderate the disease. Prescription of PA/structured exercise should therefore be based on the intended outcome (e.g., primary prevention, improvement in fitness or functional status or disease treatment), and individualised, adjusted and controlled like any other medical treatment. In addition, in line with other therapeutic agents, exercise shows a dose-response effect and can be individualised using different modalities, volumes and/or intensities as appropriate to the health state or medical condition. Importantly, exercise therapy is often directed at several physiological systems simultaneously, rather than targeted to a single outcome as is generally the case with pharmacological approaches to disease management. There are diseases for which exercise is an alternative to pharmacological treatment (such as depression), thus contributing to the goal of deprescribing of potentially inappropriate medications (PIMS). There are other conditions where no effective drug therapy is currently available (such as sarcopenia or dementia), where it may serve a primary role in prevention and treatment. Therefore, this consensus statement provides an evidence-based rationale for using exercise and PA for health promotion and disease prevention and treatment in older adults. Exercise prescription is discussed in terms of the specific modalities and doses that have been studied in randomised controlled trials for their effectiveness in attenuating physiological changes of ageing, disease prevention, and/or improvement of older adults with chronic disease and disability. Recommendations are proposed to bridge gaps in the current literature and to optimise the use of exercise/PA both as a preventative medicine and as a therapeutic agent.

SARCOPENIA IN PRIMARY CARE: SCREENING, DIAGNOSIS, MANAGEMENT.

Detection of sarcopenia in primary care is a first and essential step in community-dwelling older adults before implementing preventive interventions against the onset of disabling conditions. In fact, leaving this condition undiagnosed and untreated can impact on the individual's quality of life and function, as well as on healthcare costs. This article summarizes the many instruments today available for promoting an earlier and prompter detection of sarcopenia in primary care, combining insights about its clinical management. Primary care physicians may indeed play a crucial role in the identification of individuals exposed to the risk of sarcopenia or already presenting this condition. To confirm the suspected diagnosis, several possible techniques may be advocated, but it is important that strategies are specifically calibrated to the needs, priorities and resources of the setting where the evaluation is conducted. To tackle sarcopenia, nutritional counselling and physical activity programs are today the two main interventions to be proposed. Multicomponent and personalized exercise programs can (and should) be prescribed by primary care physicians, taking advantage of validated programs ad hoc designed for this purpose (e.g., the Vivifrail protocol). It is possible that, in the next future, new pharmacological treatments may become available for tackling the skeletal muscle decline. These will probably find application in those individuals non-responding to lifestyle interventions.

Physical Functional Assessment in Older Adults.

The evaluation of the physical domain represents a critical part of the assessment of the older person, both in the clinical as well as the research setting. To measure physical function, clinicians and researchers have traditionally relied on instruments focusing on the capacity of the individual to accomplish specific functional tasks (e.g., the Activities of Daily Living [ADL] or the Instrumental ADL scales). However, a growing number of physical performance and muscle strength tests has been developed in parallel over the past three decades. These measures are specifically designed to: 1) provide objective results (not surprisingly, they are frequently timed tests) taken in standardized conditions, whereas the traditional physical function scales are generally self- or proxy-reported measures; 2) be more sensitive to changes; 3) capture the real biology of the function through the assessment of standardized tasks mirroring specific functional subdomains; and 4) mirror the quality of specific mechanisms underlying more complex and multidomain functions. Among the most commonly used instruments, the usual gait speed test, the Short Physical Performance Battery, the handgrip strength, the Timed Up-and-Go test, the 6-minute walk test, and the 400-meter walk test are widely adopted by clinicians and researchers. The clinical and research importance of all these instruments has been demonstrated by their predictive capacity for negative health-related outcomes (i.e., hospitalization, falls, institutionalization, disability, mortality). Moreover, they have shown to be associated with subclinical and clinical conditions that are also not directly related to the physical domain (e.g., inflammation, oxidative stress, overall mortality). For this reason, they have been repeatedly indicated as markers of wellbeing linked to the burden of multiple chronic conditions rather than mere parameters of mobility or strength. In this work protocols of the main tests for the objective assessment of physical function in older adults are presented.

The sarcopenia and physical frailty in older people: multi-component treatment strategies (SPRINTT) project: description and feasibility of a nutrition intervention in community-dwelling older Europeans.

BACKGROUND: The "Sarcopenia and Physical Frailty in Older People: Multicomponent Treatment Strategies" (SPRINTT) project sponsored a multi-center randomized controlled trial (RCT) with the objective to determine the effect of physical activity and nutrition intervention for prevention of mobility disability in community-dwelling frail older Europeans. We describe here the design and feasibility of the SPRINTT nutrition intervention, including techniques used by nutrition interventionists to identify those at risk of malnutrition and to carry out the nutrition intervention. METHODS: SPRINTT RCT recruited older adults (≥ 70 years) from 11 European countries. Eligible participants (n = 1517) had functional limitations measured with Short Physical Performance Battery (SPPB score 3-9) and low muscle mass as determined by DXA scans, but were able to walk 400 m without assistance within 15 min. Participants were followed up for up to 3 years. The nutrition intervention was carried out mainly by individual nutrition counseling. Nutrition goals included achieving a daily protein intake of 1.0-1.2 g/kg body weight, energy intake of 25-30 kcal/kg of body weight/day, and serum vitamin D concentration ≥ 75 mmol/L. Survey on the method strategies and feasibility of the nutrition intervention was sent to all nutrition interventionists of the 16 SPRINTT study sites. RESULTS: Nutrition interventionists from all study sites responded to the survey. All responders found that the SPRINTT nutrition intervention was feasible for the target population, and it was well received by the majority. The identification of participants at nutritional risk was accomplished by combining information from interviews, questionnaires, clinical and laboratory data. Although the nutrition intervention was mainly carried out using individual nutritional counselling, other assisting methods were used as appropriate. CONCLUSION: The SPRINTT nutrition intervention was feasible and able to adapt flexibly to varying needs of this heterogeneous population. The procedures adopted to identify older adults at risk of malnutrition and to design the appropriate intervention may serve as a model to deliver nutrition intervention for community-dwelling older people with mobility limitations.

Prevalence of Prefrailty and Frailty in South America: A Systematic Review of Observational Studies.

OBJECTIVES: The present study aimed at investigating the prevalence of prefrailty and frailty in South American older adults according to the setting and region. DESIGN: A literature search combining the terms "frailty", "South America" or a specific country name was performed on PubMed, EMBASE, Lilacs, and Scielo to retrieve articles published in English, Portuguese or Spanish on or before August 2019. PARTICIPANTS: Older adults aged 60+ years from any setting classified as frail according to a validated scale were included in the study. MEASUREMENTS: Frailty assessment by a validated scale. RESULTS: One-hundred eighteen reports (98 performed from Brazil, seven from Chile, five from Peru, four from Colombia, two from Ecuador, one from Argentina, and one from Venezuela) were included in the study. The mean prevalence of prefrailty in South America was 46.8% (50.7% in older in-patients, 47.6% in the community, and 29.8% in nursing-home residents). The mean prevalence of frailty in South America was 21.7% (55.8% in nursing-home residents, 39.1% in hospitalized older adults, and 23.0% in the community). CONCLUSIONS: Prefrailty and frailty are highly prevalent in South American older adults, with rates higher than those reported in Europe and Asia. In the community, almost one-in-two is prefrail and one-in-five is frail, while hospitalized persons and nursing-home residents are more frequently affected. These findings indicate the need for immediate attention to avoid frailty progression toward negative health outcomes. Our findings also highlight the need for specific guidelines for the management of frailty in South America.

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.

Effects of aging and life-long moderate calorie restriction on IL-15 signaling in the rat white adipose tissue.

OBJECTIVE: Phosphorylation of insulin receptor substrate (IRS) 1 by tumor necrosis factor alpha (TNF-α) has been implicated as a factor contributing to insulin resistance. Administration of IL-15 reduces adipose tissue deposition in young rats and stimulates secretion of adiponectin, an insulin sensitizing hormone that inhibits the production and activity of TNF-α. We aimed at investigating the effects of age life-long moderate calorie restriction (CR) on IL-15 and TNF-α signaling in rat white adipose tissue (WAT). MATERIALS AND METHODS: Thirty-six 8-month-old, 18-month-old, and 29-month-old male Fischer344´Brown Norway F1 rats (6 per group) were either fed ad libitum (AL) or calorie restricted by 40%. The serum levels of IL-15 and IL-15 receptor α-chain (IL-15Rα) were increased by CR controls regardless of age. An opposite pattern was detected in WAT. In addition, CR reduced gene expression of TNF-α and cytosolic IRS1 serine phosphorylation in WAT, independently from age. RESULTS: IL-15 signaling in WAT is increased over the course of aging in AL rats compared with CR rodents. Protein levels of IL-15Rα are greater in WAT of AL than in CR rats independently from age. This adaptation was paralleled by increased IRS1 phosphorylation through TNF-α-mediated insulin resistance. Adiponectin decreased at old age in AL rats, while no changes were evident in CR rats across age groups. CONCLUSIONS: IL-15 signaling could therefore represent a potential target for interventions to counteract metabolic alterations and the deterioration of body composition during aging.

Clinical and radiographic outcomes in patients operated for complex open tibial pilon fractures.

AIM: To report clinical and radiographic results of treatment of patients with complex open tibial pilon fractures. METHODS: A retrospective analysis in 14 patients with complex open pilon fractures treated between 2010 and 2015 was conducted. The injuries were graded according to AO Classification and the Gustillo-Anderson system. Routine follow-up was performed at 1, 3, 6, 12 month with an annual evaluation thereafter. All patients were included for the assessment of the rate of infection, wound and fracture-healing. Functional outcome assessment was performed in all patients according to the American Orthopedic Foot and Ankle Score (AOFAS) at 12 months after the injury. The radiological outcome was evaluated through standard XR using the criteria proposed by Burwell and Charnley. RESULTS: Analysis were conducted in 12 men and 2 women, with a mean age of 50.4 years (20-77) who were followed up for an average 34 months (range: 9-60 months). All patients had a AO type 43C fracture. There were three Gustilo Type IIIA injuries, seven Type III B and four Type III C. The mean time to fracture healing was 6.3 months. 4 patients underwent definitive treatment with external fixation at the time of the initial irrigation and debridement. 10 patients underwent delayed definitive surgery: in 10 patients ORIF was used. Soft-tissue coverage by vascularized muscle flap was necessary in 4 patients (28%) and was typically performed on the day of definitive fixation. One patient required iliac crest bone-grafting. 4 patients (28%) had a deep infection.6 patients (43%) had a superficial pin infection or cellulitis. 6 patients (43%) presented delayed union. The average AOFAS score was 71.5 (40-95). According to the Burwell-Charnley score, the anatomical reduction of the fracture was obtained in 50% of patients and a good reduction in 86% of cases. 5 patients (35.7%) had loss of joint congruity and evidence of osteoarthritis on radiographs at final follow-up. No patient needed arthrodesis or amputation. CONCLUSION: The results of our study suggest that open tibial pilon fractures can be safely managed with low rate of complications using intensive debridement, antibiotics, adequate devices and patient-tailored timing of definitive surgical treatment.

Proceedings of the Canadian Frailty Network Workshop: Identifying Biomarkers of Frailty to Support Frailty Risk Assessment, Diagnosis and Prognosis. Toronto, January 15, 2018.

The Canadian Frailty Network (CFN), a pan-Canadian not-for-profit organization funded by the Government of Canada through the Networks of Centres of Excellence Program, is dedicated to improving the care of older Canadians living with frailty. The CFN has partnered with the Canadian Longitudinal Study on Aging (CLSA) to measure potential frailty biomarkers in biological samples (whole blood, plasma, urine) collected in over 30,000 CLSA participants. CFN hosted a workshop in Toronto on January 15 2018, bringing together experts in the field of biomarkers, aging and frailty. The overall objectives of the workshop were to start building a consensus on potential frailty biomarker domains and identify specific frailty biomarkers to be measured in the CLSA biological samples. The workshop was structured with presentations in the morning to frame the discussions for the afternoon session, which was organized as a free-flowing discussion to benefit from the expertise of the participants. Participants and speakers were from Canada, Italy, Spain, United Kingdom and the United States. Herein we provide pertinent background information, a summary of all the presentations with key figures and tables, and the distillation of the discussions. In addition, moving forward, the principles CFN will use to approach frailty biomarker research and development are outlined. Findings from the workshop are helping CFN and CLSA plan and conduct the analysis of biomarkers in the CLSA samples and which will inform a follow-up data access competition.

Older HIV-infected adults: complex patients- geriatric syndromes (II).

With the widespread adoption of highly active antiretroviral therapy (HAART), HIV infection starts to be considered one of the many chronic illnesses of advanced age. A growing proportion of the affected patients is presently older than 50. It has been suggested that HIV infection may today represent a model of accelerated and accentuated ageing. The need for a closer collaboration between geriatricians and HIV physicians is being growingly recognised to better address the priorities and needs of HIV patients. The final aim behind the generation of such synergies resides in the design of personalised plans of interventions. These plans should stem from the results of a comprehensive assessment of the individual spanning clinical, environmental, and psychosocial domains. Through the early identification of stressors and risk factors potentially disrupting the homeostatic balance of frail patients (including those living with HIV), it might be possible to protect the "biologically old" (but not necessarily "chronologically old") HIV-infected people from developing detrimental geriatric syndromes. In this article, specific features making the ageing HIV population of special interest for geriatric medicine, and the importance of a multidisciplinary model of care are described. The final objective is to stress how the only way for adequately tackling the multifaceted frailty condition of people with HIV is to implement novel models of care based on the comprehensive geriatric assessment.

Animal-Derived Protein Consumption Is Associated with Muscle Mass and Strength in Community-Dwellers: Results from the Milan EXPO Survey.

OBJECTIVES: Behavioral factors, including protein intake, influence the quantity and quality of skeletal muscle. The aim of this study was to explore the relationship between animal-derived protein intake and muscle mass and function in a large sample of unselected community-dwellers. MATERIAL AND METHODS: The VIP (Very Important Protein) study, conducted during Expo 2015 in Milan, was a population survey aimed at assessing major health metrics in a population outside of the research setting, with a special focus on the relation between animal-derived protein intake and muscle mass and function. A brief questionnaire exploring lifestyle habits, dietary preferences and the consumption of selected foods was administered. Muscle mass was estimated by calf circumference (CC) and mid-arm muscle circumference (MAMC) of the dominant side. Muscle strength of upper and lower extremities was assessed through handgrip strength testing and repeated chair stand test, respectively. RESULTS: The mean age of the 1,853 participants was 50.3 years (standard deviation: 15.7; range: 18-98 years), of whom 959 (51.7%) were women. Participants in the highest tertile of protein consumption showed better performance at both the handgrip strength (p <0.001) and chair stand tests than those in the lowest tertile (p <0.01). The same results were found for CC (p <0.001) and MAMC (p <0.001). Participants with high protein intake and engaged in regular physical activity showed the higher scores in all the assessed domains. CONCLUSIONS: The results of the VIP survey suggest an association between animal-derived protein intake and muscle mass and strength across ages. Our findings also indicate a synergistic effect of animal-derived protein intake and physical activity on muscle-related parameters.

The association between sarcopenia and functional outcomes among older patients with hip fracture undergoing in-hospital rehabilitation.

This study evaluates the prevalence of sarcopenia among older people admitted to a rehabilitation unit after hip fracture and the association between sarcopenia and functional outcomes. The results show that sarcopenia had a negative impact on functional recovery. The assessment of sarcopenia among older adults receiving rehabilitation programs is crucial. INTRODUCTION: Sarcopenia is a highly prevalent geriatric syndrome associated with adverse outcomes, including falls, disability, institutionalization, and mortality. Few studies assessed sarcopenia among older adults receiving rehabilitation programs. METHODS: Patients aged 70 years or more consecutively admitted to in-hospital rehabilitation programs that had suffered from hip fracture entered the study. Sarcopenia was defined according to the Foundation for National Institutes of Health (FNIH) criteria. Multivariable linear regression models were used to analyze the association between the sarcopenia and functional recovery. RESULTS: The recruited population was composed of 127 patients, with a mean age of 81.3 ± 4.8 years, predominantly females (64.6%). Using the criteria proposed by the FNIH, patients with a diagnosis of sarcopenia were 43 (33.9%). After adjustment for potential confounders, participants with sarcopenia had a significant increased risk of incomplete functional recovery compared with non-sarcopenic patients (OR 3.07, 95% CI 1.07-8.75). Compared with participants without sarcopenia, those with sarcopenia showed lower Barthel index scores at the time of discharge from the rehabilitation unit (69.2 versus 58.9, respectively; p < 0.001) and after 3 months of follow-up (90.9 versus 80.5, respectively; p = 0.02). CONCLUSIONS: These findings support the systematic assessment of sarcopenia among older adults receiving rehabilitation programs to assist in the development of personalized treatment plans aimed at improving functional outcomes.