Nalin Singh

Effects of High-Intensity Progressive Resistance Training and Targeted Multidisciplinary Treatment of Frailty on Mortality and Nursing Home Admissions after Hip Fracture: A Randomized Controlled Trial

RATIONALE Excess mortality and residual disability are common after hip fracture. HYPOTHESIS Twelve months of high-intensity weight-lifting exercise and targeted multidisciplinary interventions will result in lower mortality, nursing home admissions, and disability compared with usual care after hip fracture. DESIGN Randomized, controlled, parallel-group superiority study. SETTING Outpatient clinic PARTICIPANTS Patients (n = 124) admitted to public hospital for surgical repair of hip fracture between 2003 and 2007. INTERVENTION Twelve months of geriatrician-supervised high-intensity weight-lifting exercise and targeted treatment of balance, osteoporosis, nutrition, vitamin D/calcium, depression, cognition, vision, home safety, polypharmacy, hip protectors, self-efficacy, and social support. OUTCOMES Functional independence: mortality, nursing home admissions, basic and instrumental activities of daily living (ADLs/IADLs), and assistive device utilization. RESULTS Risk of death was reduced by 81% (age-adjusted OR [95% CI] = 0.19 [0.04-0.91]; P < .04) in the HIPFIT group (n = 4) compared with usual care controls (n = 8). Nursing home admissions were reduced by 84% (age-adjusted OR [95% CI] = 0.16 [0.04-0.64]; P < .01) in the experimental group (n = 5) compared with controls (n = 12). Basic ADLs declined less (P < .0001) and assistive device use was significantly lower at 12 months (P = .02) in the intervention group compared with controls. The targeted improvements in upper body strength, nutrition, depressive symptoms, vision, balance, cognition, self-efficacy, and habitual activity level were all related to ADL improvements (P < .0001-.02), and improvements in basic ADLs, vision, and walking endurance were associated with reduced nursing home use (P < .0001-.05). CONCLUSION The HIPFIT intervention reduced mortality, nursing home admissions, and ADL dependency compared with usual care.

Recurrent and Injurious Falls in the Year Following Hip Fracture: A Prospective Study of Incidence and Risk Factors From the Sarcopenia and Hip Fracture Study

BACKGROUND The incidence and etiology of falls in patients following hip fracture remains poorly understood. METHODS We prospectively investigated the incidence of, and risk factors for, recurrent and injurious falls in community-dwelling persons admitted for surgical repair of minimal-trauma hip fracture. Fall surveillance methods included phone calls, medical records, and fall calendars. Potential predictors of falls included health status, quality of life, nutritional status, body composition, muscle strength, range of motion, gait velocity, balance, walking endurance, disability, cognition, depression, fear of falling, self-efficacy, social support, physical activity level, and vision. RESULTS 193 participants enrolled in the study (81 +/- 8 years, 72% women, gait velocity 0.3 +/- 0.2 m/s). We identified 227 falls in the year after hip fracture for the 178 participants with fall surveillance data. Fifty-six percent of participants fell at least once, 28% had recurrent falls, 30% were injured, 12% sustained a new fracture, and 5% sustained a new hip fracture. Age-adjusted risk factors for recurrent and injurious falls included lower strength, balance, range of motion, physical activity level, quality of life, depth perception, vitamin D, and nutritional status, and greater polypharmacy, comorbidity, and disability. Multivariate analyses identified older age, congestive heart failure, poorer quality of life, and nutritional status as independent risk factors for recurrent and injurious falls. CONCLUSIONS Recurrent and injurious falls are common after hip fracture and are associated with multiple risk factors, many of which are treatable. Interventions should therefore be tailored to alleviating or reversing any nutritional, physiological, and psychosocial risk factors of individual patients.

The Study of Mental and Resistance Training (SMART) study—resistance training and/or cognitive training in mild cognitive impairment: a randomized, double-blind, double-sham controlled trial.

BACKGROUND Mild cognitive impairment (MCI) increases dementia risk with no pharmacologic treatment available. METHODS The Study of Mental and Resistance Training was a randomized, double-blind, double-sham controlled trial of adults with MCI. Participants were randomized to 2 supervised interventions: active or sham physical training (high intensity progressive resistance training vs seated calisthenics) plus active or sham cognitive training (computerized, multidomain cognitive training vs watching videos/quizzes), 2-3 days/week for 6 months with 18-month follow-up. Primary outcomes were global cognitive function (Alzheimers Disease Assessment Scale-cognitive subscale; ADAS-Cog) and functional independence (Bayer Activities of Daily Living). Secondary outcomes included executive function, memory, and speed/attention tests, and cognitive domain scores. RESULTS One hundred adults with MCI [70.1 (6.7) years; 68% women] were enrolled and analyzed. Resistance training significantly improved the primary outcome ADAS-Cog; [relative effect size (95% confidence interval) -0.33 (-0.73, 0.06); P < .05] at 6 months and executive function (Wechsler Adult Intelligence Scale Matrices; P = .016) across 18 months. Normal ADAS-Cog scores occurred in 48% (24/49) after resistance training vs 27% (14/51) without resistance training [P < .03; odds ratio (95% confidence interval) 3.50 (1.18, 10.48)]. Cognitive training only attenuated decline in Memory Domain at 6 months (P < .02). Resistance training 18-month benefit was 74% higher (P = .02) for Executive Domain compared with combined training [z-score change = 0.42 (0.22, 0.63) resistance training vs 0.11 (-0.60, 0.28) combined] and 48% higher (P < .04) for Global Domain [z-score change = .0.45 (0.29, 0.61) resistance training vs 0.23 (0.10, 0.36) combined]. CONCLUSIONS Resistance training significantly improved global cognitive function, with maintenance of executive and global benefits over 18 months.

Methodology and Baseline Characteristics for the Sarcopenia and Hip Fracture Study: A 5-Year Prospective Study

BACKGROUND Age-related hip fractures are associated with poor functional outcomes, resulting in substantial personal and societal burden. There is a need to better identify reversible etiologic predictors of suboptimal functional recovery in this group. METHODS The Sarcopenia and Hip Fracture (SHIP) study was a 5-year prospective cohort study following community-dwelling older persons admitted to three Sydney hospitals for hip fracture. Information was collected at baseline, and 4 and 12 months, including health status, quality of life, nutritional status, body composition, muscle strength, range of motion, gait velocity, balance, walking endurance, disability, cognition, depression, fear of falling, self-efficacy, social support, physical activity level, vision, and fall-related data, with residential status, disability, and mortality reassessed at 5 years. RESULTS 193 participants enrolled (81 +/- 8 years, 72% women). High levels of activities of daily living, disability and sedentariness were present prior to fracture. At admission, the cohort had high levels of chronic disease; 38% were depressed, 38% were cognitively impaired, and 26% had heart disease. Seventy-one percent of participants were sarcopenic, 58% undernourished, and 55% vitamin D deficient. Mobility, strength, and vision were severely impaired. There was little evidence that these comorbidities were either recognized or treated during hospitalization. Disability, sedentariness, malnutrition, and walking endurance predicted acute hospitalization length of stay. CONCLUSIONS The complex comorbidity, pre-existing functional impairment, and sedentary behavior in patients with hip fracture suggest the need for thorough screening and targeting of potentially reversible impairments. Rehabilitation outcomes are likely to be highly dependent on amelioration of these highly prevalent accompaniments to hip fracture.

Resistance training improves cardiac output, exercise capacity and tolerance to positive airway pressure in Fontan physiology☆

BACKGROUND Subjects with Fontan-type circulation have no sub-pulmonary ventricle and thus depend exquisitely on the respiratory bellows and peripheral muscle pump for cardiac filling. We hypothesised that resistance training to augment the peripheral muscle pump might improve cardiac filling, reduce inspiratory-dependence of IVC return to the heart and thus improve exercise capacity and cardiac output on constant positive airway pressure (CPAP). METHODS Eleven Fontan subjects (32+/-2 years, mean+/-SEM) had cardiac magnetic resonance imaging (MRI) and exercise testing (CPET); six underwent 20 weeks of high-intensity resistance training; others were non-exercising controls. After training, CPET was repeated. Four trainers had MRI with real-time flow measurement at rest, exercise and on CPAP in the trained state and following a 12-month detrain. RESULTS In the trained state, muscle strength increased by 43% (p=0.002), as did total muscle mass (by 1.94 kg, p=0.003) and peak VO2 (by 183 ml/min, p=0.02). After detraining, calf muscle mass and peak workload had fallen significantly (p<0.03 for both) as did peak VO2 (2.72 vs. 2.18 l/min, p<0.001) and oxygen pulse, a surrogate for SV (16% lower, p=0.005). Furthermore after detraining, SV on MRI decreased at rest (by 11 ml, p=0.01) and during moderate-intensity exercise (by 16 ml, p=0.04); inspiratory-dependent IVC blood return during exercise was 40% higher (p=0.02). On CPAP, cardiac output was lower in the detrained state (101 vs. 77 ml/s, p=0.03). CONCLUSIONS Resistance muscle training improves muscle mass, strength and is associated with improved cardiac filling, stroke volume, exercise capacity and cardiac output on CPAP, in adults with Fontan-type circulation.

Changes in insulin resistance and HbA1c are related to exercise-mediated changes in body composition in older adults with type 2 diabetes: interim outcomes from the GREAT2DO trial.

OBJECTIVE To investigate changes in body composition after 12 months of high-intensity progressive resistance training (PRT) in relation to changes in insulin resistance (IR) or glucose homeostasis in older adults with type 2 diabetes. RESEARCH DESIGN AND METHODS One-hundred three participants were randomized to receive either PRT or sham exercise 3 days per week for 12 months. Homeostasis model assessment 2 of insulin resistance (HOMA2-IR) and glycosylated hemoglobin (HbA1c) were used as indices of IR and glucose homeostasis. Skeletal muscle mass (SkMM) and total fat mass were assessed using bioelectrical impedance. Visceral adipose tissue, mid-thigh cross-sectional area, and mid-thigh muscle attenuation were quantified using computed tomography. RESULTS Within the PRT group, changes in HOMA2-IR were associated with changes in SkMM (r = −0.38; P = 0.04) and fat mass (r = 0.42; P = 0.02). Changes in visceral adipose tissue tended to be related to changes in HOMA2-IR (r = 0.35; P = 0.07). Changes in HbA1c were related to changes in mid-thigh muscle attenuation (r = 0.52; P = 0.001). None of these relationships were present in the sham group (P > 0.05). Using ANCOVA models, participants in the PRT group who had increased SkMM had decreased HOMA2-IR (P = 0.05) and HbA1c (P = 0.09) compared with those in the PRT group who lost SkMM. Increases in SkMM in the PRT group decreased HOMA2-IR (P = 0.07) and HbA1c (P < 0.05) compared with those who had increased SkMM in the sham group. CONCLUSIONS Improvements in metabolic health in older adults with type 2 diabetes were mediated through improvements in body composition only if they were achieved through high-intensity PRT.

Study of Mental Activity and Regular Training (SMART) in at risk individuals: a randomised double blind, sham controlled, longitudinal trial.

BackgroundThe extent to which mental and physical exercise may slow cognitive decline in adults with early signs of cognitive impairment is unknown. This article provides the rationale and methodology of the first trial to investigate the isolated and combined effects of cognitive training (CT) and progressive resistance training (PRT) on general cognitive function and functional independence in older adults with early cognitive impairment: Study of Mental and Regular Training (SMART). Our secondary aim is to quantify the differential adaptations to these interventions in terms of brain morphology and function, cardiovascular and metabolic function, exercise capacity, psychological state and body composition, to identify the potential mechanisms of benefit and broader health status effects.MethodsSMART is a double-blind randomized, double sham-controlled trial. One hundred and thirty-two community-dwelling volunteers will be recruited. Primary inclusion criteria are: at risk for cognitive decline as defined by neuropsychology assessment, low physical activity levels, stable disease, and age over 55 years. The two active interventions are computerized CT and whole body, high intensity PRT. The two sham interventions are educational videos and seated calisthenics. Participants are randomized into 1 of 4 supervised training groups (2 d/wk × 6 mo) in a fully factorial design. Primary outcomes measured at baseline, 6, and 18 months are the Alzheimers Disease Assessment Scale (ADAS-Cog), neuropsychological test scores, and Bayer Informant Instrumental Activities of Daily Living (B-IADLs). Secondary outcomes are psychological well-being, quality of life, cardiovascular and musculoskeletal function, body composition, insulin resistance, systemic inflammation and anabolic/neurotrophic hormones, and brain morphology and function via Magnetic Resonance Imaging (MRI) and Spectroscopy (fMRS).DiscussionSMART will provide a novel evaluation of the immediate and long term benefits of CT, PRT, and combined CT and PRT on global cognitive function and brain morphology, as well as potential underlying mechanisms of adaptation in older adults at risk of further cognitive decline.Trial RegistrationAustralia and New Zealand Clinical Trials Register (ANZCTR): ANZCTRN12608000489392

Mediation of Cognitive Function Improvements by Strength Gains After Resistance Training in Older Adults with Mild Cognitive Impairment: Outcomes of the Study of Mental and Resistance Training

To determine whether improvements in aerobic capacity (VO2peak) and strength after progressive resistance training (PRT) mediate improvements in cognitive function.

Continuous Hemodynamic Response to Maximal Dynamic Strength Testing in Older Adults

OBJECTIVE To quantify acute changes in blood pressure and heart rate during a maximal dynamic strength-single-repetition maximum lift (1-RM)-testing session in older adults with a low burden of chronic disease. DESIGN Descriptive, cross-sectional study. SETTING University rehabilitation center. PARTICIPANTS Volunteer sample of 43 community-dwelling, nonresistance-trained older adults aged 60 years and older (mean, 68+/-6y). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Systolic blood pressure (SBP), diastolic blood pressure (DBP), and heart rate was obtained by plethysmography at rest and during 1-RM strength testing on leg press, knee extension, and knee flexion resistance machines. RESULTS Average resting SBP (132+/-28mmHg), DBP (54+/-15mmHg), and heart rate (65+/-11 beats/min) were independent of hypertensive diagnosis and overweight status. Maximal SBP, DBP, and heart rate increased significantly during the 1-RM in all exercises compared with rest (P<.001). Highest values of SBP (236+/-51mmHg) and DBP (140+/-46mmHg) were measured during the leg press at 99.5%+/-6.7% of 1-RM. Lowest values of SBP (79+/-25mmHg) and DBP (38+/-15mmHg), and the highest (123+/-44 beats/min) and lowest heart rate (41+/-23 beats/min) were measured during the knee extension at 97.4%+/-8.1% of 1-RM. Absolute falls in SBP were greatest in treated hypertensive participants. No cardiovascular symptoms or events occurred in 129 1-RM tests. CONCLUSIONS Large, very transient, asymptomatic excursions in blood pressure and heart rate were measured during 1-RM testing. The most robust hemodynamic response occurred during the leg press. Thus the leg press may be the most important exercise to focus hemodynamic monitoring efforts upon during strength testing in clinical cohorts.

P4-399: The somatotrophics, memory and aging research trial (SMART): Study of mental activity & resistance training for the prevention of cognitive impairment in at-risk older individuals

Background: Epidemiological, basic science and clinical evidence suggests that cognitive and physical exercise may benefit brain function in late life. Potentially protective neurobiological effects include adaptations in cortical volume, neuropeptides, functional activation, cytokines, body composition and insulin sensitivity. Delaying the onset of dementia and age-related cognitive impairment through cognitive and physical activity may therefore be a realistic goal, however this has yet to be fully tested in a RCT. In particular, the possibility of synergistic effects between cognitive and physical activity has not been robustly evaluated. Methods: A fully factorial, double-blind, placebo controlled and longitudinal randomized clinical trial. 182 initially non-demented older individuals at-risk for dementia by virtue of borderline cognitive function will be recruited and randomly assigned to one of four intervention conditions in equal numbers. Eligible individuals will be older than 65 years without dementia or depression, physically and linguistically capable of completing supervised cognitive and physical exercise, and at-risk defined as corrected MMSE 23-27. Interventions: 1. Cognitive exercise: 6 months of thrice weekly 1 hour sessions of computer-based multi-modal cognitive exercise plus sham physical exercise (stretching). 2. Physical exercise: 6 months of thrice weekly 1 hour sessions of progressive resistance exercise plus sham cognitive exercise (lectures). 3. Combined exercise: both active cognitive and physical exercise. 4. Double Sham Control group: both sham cognitive and physical exercise. Results: Will occur at 0 (baseline), 6 months (immediately after the intervention: proximal follow-up) and 18 months (longitudinal follow- up). These will include: Neuropsychological battery including ADASCog; Neuropsychiatric evaluation; Magnetic Resonance Imaging (MRI) brain scans; Mood and well-being; Physical fitness and functional performance; and Systemic inflammation, metabolism, nutritional biochemistry. Conclusions: Primary: To determine whether active interventions lead to a differential rate of cognitive decline at longitudinal follow-up compared to the placebo group, and whether combined mental and physical exercise is more effective than either modality alone. Secondary: To determine whether active intervention effects are mediated by specific changes in brain structure and function, or via alterations in metabolism, body composition or systemic inflammation. To determine whether active intervention effects are associated with improved mood and well-being.