Julio C. Moriguti

(Pre)diabetes, brain aging, and cognition.

Cognitive dysfunction and dementia have recently been proven to be common (and underrecognized) complications of diabetes mellitus (DM). In fact, several studies have evidenced that phenotypes associated with obesity and/or alterations on insulin homeostasis are at increased risk for developing cognitive decline and dementia, including not only vascular dementia, but also Alzheimers disease (AD). These phenotypes include prediabetes, diabetes, and the metabolic syndrome. Both types 1 and 2 diabetes are also important risk factors for decreased performance in several neuropsychological functions. Chronic hyperglycemia and hyperinsulinemia primarily stimulates the formation of Advanced Glucose Endproducts (AGEs), which leads to an overproduction of Reactive Oxygen Species (ROS). Protein glycation and increased oxidative stress are the two main mechanisms involved in biological aging, both being also probably related to the etiopathogeny of AD. AD patients were found to have lower than normal cerebrospinal fluid levels of insulin. Besides its traditional glucoregulatory importance, insulin has significant neurothrophic properties in the brain. How can clinical hyperinsulinism be a risk factor for AD whereas lab experiments evidence insulin to be an important neurothrophic factor? These two apparent paradoxal findings may be reconciliated by evoking the concept of insulin resistance. Whereas insulin is clearly neurothrophic at moderate concentrations, too much insulin in the brain may be associated with reduced amyloid-beta (Abeta) clearance due to competition for their common and main depurative mechanism - the Insulin-Degrading Enzyme (IDE). Since IDE is much more selective for insulin than for Abeta, brain hyperinsulinism may deprive Abeta of its main clearance mechanism. Hyperglycemia and hyperinsulinemia seems to accelerate brain aging also by inducing tau hyperphosphorylation and amyloid oligomerization, as well as by leading to widespread brain microangiopathy. In fact, diabetes subjects are more prone to develop extense and earlier-than-usual leukoaraiosis (White Matter High-Intensity Lesions - WMHL). WMHL are usually present at different degrees in brain scans of elderly people. People with more advanced WMHL are at increased risk for executive dysfunction, cognitive impairment and dementia. Clinical phenotypes associated with insulin resistance possibly represent true clinical models for brain and systemic aging.

Efeito da reabilitação vestibular sobre a qualidade de vida de idosos labirintopatas

Dizziness is a symptom that affects the population world over, being more prevalent in the elderly due to the process of functional deterioration of the hearing and vestibular systems with aging. AIM: The objective of this study was to evaluate prospectively the effect of Vestibular Rehabilitation (VR) as treatment for labyrinth disease of vascular and metabolic origin in the quality of life of geriatric patients. METHODS: The study was outlined as clinical-prospective, longitudinal, and observed, with the participation of 40 elder citizens of both genders, divided in 2 groups, dizziness of vascular or metabolic origin. The patients were evaluated and underwent VR - based on Cawthorne and Cookseys protocol. The statistical analysis from the data was done through the t-Student test, the coefficients of Pearson and Spearman. RESULTS: based on quality of life scales showed that the individuals treated and assessed improved after Vestibular Rehabilitation. CONCLUSION: we concluded that VR, based on the protocols of Cawthorne and Cooksey, could be beneficial to this population

Association of frailty syndrome in the elderly with higher blood pressure and other cardiovascular risk factors.

BACKGROUND Few studies have evaluated blood pressure (BP) and cardiovascular risk in older persons with frailty syndrome. The objective of the present study was to assess the cardiovascular risk factors of subjects with frailty syndrome with emphasis on BP, as compared with individuals without frailty or with prefrailty. METHODS This was a cross-sectional study in which 77 frail, prefrail, and nonfrail older subjects were selected according to the criteria of Fried et al.: self-reported weight loss, low grip strength, low energy, slow gait speed, and low physical activity. Anthropometric and BP measurements were obtained in the office, and home blood pressure monitoring (HBPM) and ambulatory blood pressure monitoring (ABPM) were also performed. Fasting glucose and plasma lipids were collected. Data were analyzed by linear fixed effects model and ANOVA. RESULTS Mean age was 74.5 ± 7.5 years. There was no difference in office BP or HBPM between groups, but ABPM of frail group demonstrated higher systolic and diastolic BP values over the 24 h (135/74 mm Hg, P = 0.02 and P = 0.04) and during sleep (135/74 mm Hg, P = 0.01 and P = 0.02) than nonfrail group (122/68 mm Hg and 120/67 mm Hg, respectively). Body mass index and fasting glucose were similar among groups, although abdominal circumference was greater (P = 0.04) and high-density lipoproteins (HDL) were lower (P = 0.03) in the frail group than nonfrail one (P = 0.04). CONCLUSIONS Subjects with frailty syndrome had higher BP evaluated by ABPM and other cardiovascular risk factors such as lower HDL and more abdominal fat than nonfrailty group.

Involuntary weight loss in elderly individuals: assessment and treatment.

CONTEXT The loss of body weight and fat late in life is associated with premature death and increased risk of disability, even after excluding elderly subjects who have a preexisting disease. Although it is important to recognize that periods of substantially positive or negative energy balance and body weight fluctuation occur as a normal part of life, weight losses greater than 5% over 6 months should be investigated. We can divide the major causes of weight loss in the elderly into 4 categories: social, psychiatric, due to medical conditions, and age-related. The clinical evaluation should include a careful history and physical examination. If these fail to provide clues to the weight loss, simple diagnostic tests are indicated. A period of watchful waiting is preferable to blind pursuit of additional diagnostic testing that may yield few useful data, if the results of these initial tests are normal. The first step in managing patients with weight loss is to identify and treat any specific causative or contributing conditions and to provide nutritional support when indicated. Non-orexigenic drugs have found an established place in the management of protein-energy malnutrition. Early attention to nutrition and prevention of weight loss during periods of acute stress, particularly during hospitalization, may be extremely important, as efforts directed at re-feeding are often unsuccessful. DESIGN Narrative review.

Cardiac tamponade: An unusual complication of pericardial cyst

Pericardial cysts are not common and rarely cause symptoms. We report a unique case of a 15-year-old male patient with cardiac tamponade clinically diagnosed who was referred for echocardiography. Transthoracic echocardiography revealed, in addition to a large pericardial effusion associated with echocardiographic signs of cardiac tamponade, an 8 x 5 cm echofree image suggesting a pericardial cyst adjacent to the right atrium. Immediately after pericardiocentesis, yielding a serosanguinous liquid, the patient showed striking clinical improvement and echocardiography demonstrated minimal pericardial effusion with persistence of the cystic image. At surgery a pericardial cyst containing a sanguinous fluid was found and the pathologic findings were consistent with hematic pericardial cyst. Thus echocardiography played a fundamental role for the diagnosis and treatment of the rare complication of a pericardial cyst documented in this patient.

Vestibular rehabilitation's effect over the quality of life of geriatric patients with labyrinth disease

UNLABELLED Dizziness is a symptom that affects the population world over, being more prevalent in the elderly due to the process of functional deterioration of the hearing and vestibular systems with aging. AIM The objective of this study was to evaluate prospectively the effect of Vestibular Rehabilitation (VR) as treatment for labyrinth disease of vascular and metabolic origin in the quality of life of geriatric patients. METHODS The study was outlined as clinical-prospective, longitudinal, and observed, with the participation of 40 elder citizens of both genders, divided in 2 groups, dizziness of vascular or metabolic origin. The patients were evaluated and underwent VR - based on Cawthorne and Cookseys protocol. The statistical analysis from the data was done through the t-Student test, the coefficients of Pearson and Spearman. RESULTS based on quality of life scales showed that the individuals treated and assessed improved after Vestibular Rehabilitation. CONCLUSION we concluded that VR, based on the protocols of Cawthorne and Cooksey, could be beneficial to this population.

THE EFFECT OF DIFFERENT VOLUMES OF ACUTE RESISTANCE EXERCISE ON ELDERLY INDIVIDUALS WITH TREATED HYPERTENSION

Scher, LML, Ferriolli, E, Moriguti, JC, Scher, R, and Lima, NKC. The effect of different volumes of acute resistance exercise on elderly individuals with treated hypertension. J Strength Cond Res 25(4): 1016-1023, 2011-Acute resistance exercise can reduce the blood pressure (BP) of hypertensive subjects. The aim of this study was to evaluate the effect of different volumes of acute low-intensity resistance exercise over the magnitude and the extent of BP changes in treated hypertensive elderly individuals. Sixteen participants (7 men, 9 women), with mean age of 68 ± 5 years, performed 3 independent randomized sessions: Control (C: 40 minutes of rest), Exercise 1 (E1: 20 minutes, 1 lap in the circuit), and Exercise 2 (E2: 40 minutes, 2 laps in the circuit) with the intensity of 40% of 1 repetition maximum. Blood pressure was measured before (during 20 minutes) and after each session (every 5 minutes during 60 minutes) using both a mercury sphygmomanometer and a semiautomatic device (Omrom-HEM-431). After that, 24-hour ambulatory blood pressure monitoring was performed (Dyna-MAPA). Blood pressure decreased during the first 60 minutes (systolic: p < 0.01, diastolic: p < 0.05) after all exercise sessions. Only the highest volume session promoted a reduction of mean systolic 24-hour BP and awake BP (p < 0.05) after exercise, with higher diastolic BP during sleep (p < 0.05). Diastolic 24-hour BP and both systolic and diastolic BP during sleep were higher after E1 (p < 0.05). Concluding, acute resistive exercise sessions in a circuit with different volumes reduced BP during the first 60 minutes after exercise in elderly individuals with treated hypertension. However, only the highest volume promoted a reduction of mean 24-hour and awake systolic BP.

Under-reporting of food intake is frequent among Brazilian free-living older persons: a doubly labelled water study†

The assessment of food intake is essential for the development of dietetic interventions. Accuracy is low when intake is assessed by questionnaires, the under-reporting of food intake being frequent. Most such studies, however, were performed in developed countries and there is little data about the older population of developing nations. This study aimed to verify the total energy expenditure (TEE) of independent older Brazilians living in an urban area, through the doubly labelled water (DLW) method and to compare it with the reported energy intake obtained through the application of a food frequency questionnaire (FFQ). Initially, 100 volunteers aged from 60 to 75 years had their body composition determined by dual-energy X-ray absorptiometry (DEXA). Five volunteers of each quartile of body fat percentage had their energy expenditure determined by DLW. The mean age of the subjects included in this phase of the study was 66.4 +/- 3.5 years, and ten of the subjects were men. The mean TEE was 2565 +/- 614 and 2154 +/- 339 kcal.day(-1) for men and women, respectively. The Physical Activity Level (PAL) was 1.58 +/- 0.31 and 1.52 +/- 0.22, respectively. Under-reporting of food intake was highly prevalent, with a mean percentage of reported intake in relation to measured TEE of -17.7%. Thus, under-reporting of food intake is highly prevalent among Brazilian independent older persons. The DLW method is an important tool in nutritional studies and its use is to be recommended in developing countries.

Clinical and Scintigraphic Assessment of Swallowing of Older Patients Admitted to a Tertiary Care Geriatric Ward

This study aimed to verify if older patients admitted to a tertiary care geriatric ward with no spontaneous complaints of dysphagia have impaired swallowing function as detected by a specialized clinical assessment and a scintigraphic study of swallowing. Thirty patients (mean age = 76.2 years, 17 women), consecutively admitted for the treatment of acute or chronic diseases, were studied. Two control groups were also studied, one consisting of 10 healthy older persons (mean age = 69.6 years, 5 women) and the other consisting of 20 young volunteers (mean age = 25.4 years, 11 women). A complete clinical assessment of swallowing was performed by a speech pathologist. Each subject was also submitted to scintigraphic studies of oropharyngeal transit after swallowing liquid and syrup boluses labeled with 99mtechnetium phytate. Transit time, clearance time, and residuals were measured. Five patients had impairments in swallowing function detected by clinical assessment, three of them in the absence of complaints even after specific questioning. Scintigraphic transit times did not differ between the groups studied; however, residuals after syrup swallows were greater in the patient group compared with the healthy older volunteers. These findings suggest an increased risk for aspiration and the usefulness of a brief assessment of swallowing function in all patients admitted to tertiary care geriatric wards.

Body composition, physical performance and muscle quality of active elderly women

Fat gain is one of the major factors aggravating physical disability in the elderly population, which presents an increase in fat mass and a decrease in lean mass compared to the young population. For this reason it is important to assess body composition and the effects of these alterations in obese elderly women. The purpose of this study was to assess body composition, physical performance and muscle quality in active elderly women. Cross-sectional study included 75 elderly women (29 eutrophic and 46 obese) 65-80 years old. Body composition was evaluated by dual energy X-ray absorptiometry (DXA) and the physical performance was determined by 6-minute walk test (6MWT), handgrip strength (HS) and knee extension strength (KES). Muscle quality was calculated as the ratio between muscle strength and lean mass. Fat free mass, lean mass, fat mass and percent body fat were significantly higher in the obese group (p<0.05). Furthermore, the obese group showed a poorer performance than the eutrophic group in the 6MWT (432.31±66.13 m and 472.07±74.03 m, respectively, p=0.01). HS and KES did not differ between groups, however, regarding muscle quality, the obese group exhibited a impaired in comparison to the eutrophic group in the upper (11.45±2.57 kg and 13.31±2.03 kg, respectively, p<0.01) and lower limb (2.91±1.16 kg and 3.44±0.97 kg, respectively, p=0.05). The increase in muscle mass detected in the obese elderly was not sufficient to maintain adequate muscle quality and physical function, showing a negative influence of the excess of body fat.