Pushpa Suriyaarachchi

Effects of balance training using a virtual-reality system in older fallers.

Poor balance is considered a challenging risk factor for falls in older adults. Therefore, innovative interventions for balance improvement in this population are greatly needed. The aim of this study was to evaluate the effect of a new virtual-reality system (the Balance Rehabilitation Unit [BRU]) on balance, falls, and fear of falling in a population of community-dwelling older subjects with a known history of falls. In this study, 60 community-dwelling older subjects were recruited after being diagnosed with poor balance at the Falls and Fractures Clinic, Nepean Hospital (Penrith, NSW, Australia). Subjects were randomly assigned to either the BRU-training or control groups. Both groups received the usual falls prevention care. The BRU-training group attended balance training (two sessions/week for 6 weeks) using an established protocol. Change in balance parameters was assessed in the BRU-training group at the end of their 6-week training program. Both groups were assessed 9 months after their initial assessment (month 0). Adherence to the BRU-training program was 97%. Balance parameters were significantly improved in the BRU-training group (P < 0.01). This effect was also associated with a significant reduction in falls and lower levels of fear of falling (P < 0.01). Some components of balance that were improved by BRU training showed a decline after 9 months post-training. In conclusion, BRU training is an effective and well-accepted intervention to improve balance, increase confidence, and prevent falls in the elderly.

Phenotype of Osteosarcopenia in Older Individuals With a History of Falling

OBJECTIVES In older persons, the combination of osteopenia/osteoporosis and sarcopenia has been proposed as a subset of frailer individuals at higher risk of institutionalization, falls, and fractures. However, the particular clinical, biochemical, and functional characteristics of the osteosarcopenic (OS) patients remain unknown. In this study, we used a clinical definition of osteosarcopenia aiming to determine the clinical, functional, and biochemical features that are unique to these patients within a population of older people who fall. DESIGN Cross-sectional study. SETTING Falls and Fractures Clinic, Nepean Hospital (Penrith, NSW, Australia). PARTICIPANTS A total of 680 people (mean age = 79, 65% women) assessed between 2009 and 2013. MEASUREMENTS Assessment included medical history, physical examination, bone densitometry and body composition by dual-energy X-ray absorptiometry, posturography, grip strength, gait parameters (GaitRITE), and blood tests for nutrition and secondary causes of sarcopenia and osteoporosis. Patients were divided into 4 groups: (1) osteopenic (BMD <-1.0 SD), (2) sarcopenic, (3) OS, and (4) nonsarcopenic/nonosteopenic. Difference between groups was assessed with 1-way ANOVA and χ(2) analysis. Multivariable linear regression evaluated the association between the groups and measures of physical function. Multivariable logistic regression evaluated risk factors for being in the OS group. RESULTS Mean age of the OS patients was 80.4 ± 7.0 years. Our analyses showed that OS patients are older, mostly women, are at high risk for depression and malnutrition, have body mass index lower than 25, and showed a higher prevalence of peptic disease, inflammatory arthritis, maternal hip fracture, history of atraumatic fracture, and impaired mobility. CONCLUSION We have reported a set of characteristics that are highly prevalent in OS patients. This study could be used to inform the design of future trials and to develop interventions to prevent institutionalization and poor outcomes in this particular set of high-risk patients.

Vitamin D status in relation to postural stability in the elderly.

ObjectivesPostural instability (PI) is an important risk factor for falls, especially in the frail older population. In this study, we investigated the impact of vitamin D deficiency on PI in a sample of community dwelling older subjects. Our objective was to determine the potential association between vitamin D deficiency and PI in older fallers.DesignCross-sectional study.SettingFalls and Fractures Clinic, Department of Geriatric Medicine, Nepean Hospital, Penrith, Australia.ParticipantsOne hundred and forty-five adults aged 65 years and older who have had at least one episode of a fall within the six months prior to assessment at the Falls and Fractures Clinic.MeasurementsSerum 25(OH) vitamin D3 [25(OH)D3] and parathyroid hormone concentrations were determined at baseline. Subjects were separated into 3 groups based on serum 25(OH)D3 levels with the following cut-off values: < 30 nmol/L (deficient), 30–50 nmol/L (insufficient) and > 50 nmol/L (normal). Other baseline measurements included body mass index, mini-nutritional assessment, grip strength, serum calcium concentration and creatinine clearance, which were used as covariables. PI was assessed using a computerized virtual reality system (Medicaa, Uruguay). Measured parameters included limits of stability (LOS) and centre of pressure (COP) under eyes closed on foam (ECF) and visio-vestibular stimulation. The estimated swaying area, computed from the ellipse of confidence under eyes closed standing on foam (ECF), was also used as a PI parameter. Gait velocity (GV) was measured using a GaitRITE walkway system.ResultsPosture was impaired in vitamin D deficiency (<30 nmol/L) as indicated by lower LOS (90 +/− 18), higher ECF (25 +/− 10) and slower GV (55 +/− 7) as compared with the insufficient and normal groups. After adjustment for demographic, biochemical and anthropometric variables, vitamin D deficiency significantly correlated with low LOS and high COP under ECF.ConclusionLow levels of vitamin D were associated with PI. This association could also have an effect on slow GV and increased risk of falls. In conclusion, using an objective method to measure balance in older fallers we have identified a novel role of vitamin D in balance control. Prospective studies are required to confirm the effect of vitamin D on PI and elucidate the mechanisms of this association.

Comprehensive nutritional status in sarco-osteoporotic older fallers

ObjectivesIn older persons, the combination of osteoporosis and sarcopenia has been proposed as a subset of frailer individuals at higher risk of falls and fractures. However, the particular nutritional status of the sarco-osteoporotic (SOP) patients remains unknown. The goal of this study was to obtain a comprehensive picture of nutritional status in SOP patients.DesignCross-sectional study.SettingFalls & Fractures Clinic, Nepean Hospital (Penrith, Australia).Participants680 subjects (mean age=79, 65% female) assessed between 2008–2013.MeasurementsAssessment included medical history, mini-nutritional assessment, physical examination, bone densitometry and body composition by DXA, and blood tests for nutritional status (albumin, creatinine, hemoglobin, vitamin D, vitamin B-12, calcium, phosphate and folate). Patients were divided in 4 groups: 1) osteopenia/osteoporosis (BMD<−1.0 SD); 2) sarcopenia; 3) SOP; and 4) normal (no sarcopenia/no osteoporosis). Difference between groups was assessed with one-way ANOVA and chi square analysis. Multivariable linear regression evaluated the association between the groups and measures of nutritional parameters.ResultsSarcopenia was present in 47.4% of those with osteopenia (167/352) and 62.7% in those with osteoporosis (91/145). Mean age of the SOP was 80.4±7 years. SOP patients showed significantly higher prevalence of falls and fractures. Univariate analyses showed that SOP were more likely than normal to have a BMI< 25 (OR 2.42 95%CI 1.45–4.041, p<0.001), a MNA score <12 (OR 2.0, 95%CI 1.15–3.49, p<0.05), serum folate <20 nmol/L (OR 4.0 95%CI 1.35–11.87, p<0.01) and hemoglobin <120g/L (OR 2.0 95%CI 1.28–3.30, p<0.01). Multivariate analysis showed that a MNA score <12 was independently associated with SOP compared to normal when adjusted for age and gender. Hemoglobin <120g/L, BMI <25, and GDS >6 remained independently associated with SOP after adjustment for all variables including inflammatory conditions. Hypoalbuminemia (<35 g/L) was associated with just osteopenia/osteoporosis (OR: 2.03, 95%CI 1.08–3.81, p<0.01) and just sarcopenia (OR: 1.77, 95%CI 1.0–3.0, p<0.01) compared to normal. No differences in vitamin D, glomerular filtration rate, albumin, corrected calcium, phosphate, red blood cells folate or vitamin B12 levels were found between the subgroups.ConclusionsIn approaching SOP patients, early prevention protocols directed to optimize their nutritional status would be a key strategy to prevent poor outcomes such as falls and fractures in this high risk population. Therefore, nutritional assessment and early nutritional supplementation should be essential domains in this strategy.

Clinical Outcomes of Impaired Muscle and Bone Interactions

Muscle and bone are in constant interaction. With aging, there is a progressive decline in muscle mass, known as sarcopenia, as well as in bone mass, which is known as osteopenia/osteoporosis. Sarcopenia and osteoporosis increase the risk of suffering falls and fractures, respectively. In fact, the simultaneous occurrence of osteoporosis and sarcopenia has been observed in a subset of frailer individuals at higher risk of disability, falls and fractures. However, the particular clinical outcomes that are unique to the sarco-osteoporotic patients remain unknown. In this review, we propose a common mechanism of sarco-osteoporosis and summarize those clinical and biochemical features that are prevalent in sarco-osteoporotic subjects. We expect that by describing a set of biological, clinical and functional characteristics that are associated with sarco-osteoporosis, this information could be used to inform the design of future trials and to develop interventions for this particular syndrome.

Association Between Circulating Osteogenic Progenitor Cells and Disability and Frailty in Older Persons: The Nepean Osteoporosis and Frailty Study

Circulating osteogenic progenitor (COP) cells are considered as surrogates of the mesenchymal repository in the body. In this study, we hypothesized that COP cells decrease with age and that lower levels of COP cells are associated with greater frailty and disability in older persons. Using well-established clinical criteria, we quantified physical performance and disability and stratified frailty in a random sample of community-dwelling individuals enrolled in the Nepean Osteoporosis and Frailty (NOF) Study (mean age 82.8; N = 77; 70% female; 27 nonfrail, 23 prefrail, and 27 frail). Percentage of COP cells was quantified by flow cytometry. Logistic regression models estimated the relationship between the percentage of COP cells and prevalent disability, poor physical performance, and frailty. We found that aging is associated with a significant decrease in COP cells (p < .001). Lower percentages of COP cells were associated with disability and poor physical performance (p < .001). Older adults with COP cells in the lower quartile were more likely to be frail (odds ratio 2.65, 95% confidence interval 2.72-3.15, p < .001). In conclusion, COP cells in the circulation decrease with age. Lower percentages of COP cells in late life are associated with prevalent frailty and disability. Further longitudinal studies are needed to understand COP cells as a risk stratifier, biomarker, or therapeutic target and to predict disability in frail older persons.

Phenotype of sarcopenic obesity in older individuals with a history of falling

BACKGROUND Although sarcopenic obesity is associated with disability in middle-aged community-dwelling individuals, the phenotype of sarcopenic obesity in people 65 and older, especially those with a history of falls, remain unknown. To fill this knowledge gap, the goal of this study was to obtain a comprehensive phenotype of sarcopenic obesity in this high-risk population. METHODS Cross-sectional study of 680 subjects (mean age=79±9, 65% female) assessed between 2009 and 2013 at the Falls and Fractures Clinic, Nepean Hospital (Penrith, Australia). The assessment included a comprehensive examination, posturography, gait velocity, grip strength, bone densitometry and body composition by DXA, and blood tests for biochemical status. Patients were divided into four groups based on DXA and clinical criteria: 1) sarcopenic obese; 2) non-sarcopenic obese; 3) sarcopenic and; 4) non-sarcopenic/non-obese. The difference between groups was assessed by one-way ANOVA, chi-square analysis, and multivariable linear regression. RESULTS Sarcopenic obese subjects were older (81.1±7.3), mostly female and more likely to have lower bone mineral density, lower grip strength, slower gait velocity, and poor balance. Sarcopenic obese individuals also showed significantly higher parathyroid hormone and lower vitamin D. CONCLUSIONS We identified a particular set of clinical and biochemical characteristics in our subgroup of sarcopenic obese older fallers. Identification of these particular characteristics in the clinical setting is essential in order to prevent poor outcomes in this high-risk population.

Age, gender, and percentage of circulating osteoprogenitor (COP) cells: The COP Study

Abstract Circulating osteoprogenitor (COP) cells are blood‐borne cells which express a variety of osteoblastic markers and are able to form bone nodules in vivo. Whereas a high percentage of COP cells (%COP) is associated with vascular calcification, low %COP has been associated with disability and frailty. However, the reference range of %COP in age‐ and gender‐matching populations, and the age‐related changes in %COP remain unknown. A cross‐sectional study was undertaken in 144 healthy volunteers in Western Sydney (20–90 year‐old, 10 male and 10 female subjects per decade). %COP was quantified by flow cytometry. A high inter‐and intra‐rater reliability was found. In average, in this healthy population average of %COP was 0.42. There was no significant difference in %COP among the age groups. Similarly, no significant difference was found in %COP with gender, weight, height or BMI. In addition, we identified a normal reference range of %COP of 0.1–3.8%. In conclusion, in addition to the identification of steady levels of COP cells with age, we also identified a normal reference range of %COP, which could be used in future studies looking at musculoskeletal diseases in older populations. HighlightsPercentage of circulating osteoprogenitor (COP) cells is not affected by age.The normal reference range of %COP in the blood of a normal population is 0.1–3.8%.Age‐related changes in osteogenic differentiation of COP cells remain to be elucidated.

Association between High Levels of Parathyroid Hormone and Frailty: The Nepean Osteoporosis and Frailty (NOF) Study

BackgroundFrailty is associated with poor outcomes hence identification of risks factors is pivotal. Since the independent role of parathyroid hormone (PTH) in frailty remains unexplored, we aimed to determine this in a population of older individuals with a history of falling.DesignCross-sectional study.SettingFalls and Fracture Clinic, Nepean Hospital (Penrith, Australia).Participants692 subjects (mean age=79, 65% women) assessed between 2009–2015.MeasurementsAssessment included clinical examination, mood, nutrition, grip strength, gait velocity, bone densitometry and posturography. Chemistry included serum PTH, calcium, vitamin D (25(OH)D3), creatinine and albumin. Normocalcemic subjects were divided into 4 groups: (1) Normal: 25(OH)D3 >50nmol/L and PTH between 1.6-6.8pmol/L; (2) PTH responsive: low 25(OH)D3 (<50nmol/L) and high PTH (>6.8pmol/L); (3) PTH unresponsive: low 25(OH)D3 and normal PTH; (4) Hyper PTH (>6.8pmol/L) with normal 25(OH)D3. Frailty was defined using Fried’s criteria. Difference between the groups was assessed using one-way ANOVA and X2 analysis. Multinomial logistic regression evaluated the association between the groups and the number of Fried’s criteria adjusted for age, BMI, renal function, 25(OH)D3 levels, and albumin.Results22.6% subjects had high PTH levels (>6.8pmol/L). All subjects in the high PTH groups had significantly lower grip strength, gait velocity, limits of stability, and higher BMI. The PTH responsive group had a higher risk of pre-frailty (β=3.8, 95% CI = 3.42 -5.22, p<0.01) and frailty (β=8.26, 95% CI = 2.8-16.1, p<0.01). The risk of frailty was also higher in the Hyper PTH group (β=2.3, 95% CI = 1.74-4.32, p<0.01).ConclusionWe have reported an independent association of high PTH levels with high number of falls and with the clinical components of physical frailty in community dwelling older persons. Our results suggest a possible role of PTH in frailty that deserves further exploration.

High Parathyroid Hormone Levels are Associated with Osteosarcopenia in Older Individuals with a History of Falling

OBJECTIVES The combination of osteopenia/osteoporosis and sarcopenia (osteosarcopenia) defines a diagnostic subset of individuals at higher risk of falls, fractures and institutionalization. In this study we aimed to assess the potential role of high serum levels of parathyroid hormone (PTH) in osteosarcopenia. We hypothesized that a high PTH level is one of the major determinants of this syndrome. STUDY DESIGN Cross-sectional study in 400 subjects (mean age = 79, 65% women) assessed between 2009 and 2014 at the Falls and Fractures Clinic, Nepean Hospital (Penrith, Australia). MAIN OUTCOME MEASURES Medical history, physical examination, bone densitometry, body composition, posturography, grip strength, gait parameters, and blood tests for nutrition and secondary causes of sarcopenia and osteoporosis. Patients were assigned to one of four groups: 1) osteopenic/osteoporotic; 2) sarcopenic; 3) osteosarcopenic; or 4) non-sarcopenic/non-osteopenic. Patients with abnormal corrected calcium levels were excluded from analysis. Between-group differences were assessed using one-way analysis of variance and chi-squared tests. Multivariable linear regression was used to evaluate the association between the groups and PTH levels adjusted for age, vitamin D, renal function and albumin. RESULTS 24% of the subjects had a high serum PTH level with normal corrected calcium level. These subjects were older, reported more falls per year, and had lower grip strength, limits of stability, BMD, and gait velocity. Subjects with high PTH levels were more likely to be in the osteosarcopenia group than in the non-sarcopenic/non-osteopenic group (OR 6.88; CI: 1.9-9.2). CONCLUSIONS We reported an independent association between high PTH levels and osteosarcopenia. Our results suggest an important role of PTH in osteosarcopenia that deserves further exploration.