Robert S. Schwartz

Involuntary weight loss in older outpatients: incidence and clinical significance.

OBJECTIVES: To describe the incidence, anthropometric parameters, and clinical significance of weight loss in older outpatients.

Prospective study of serum 25-hydroxyvitamin D level, cardiovascular disease mortality, and all-cause mortality in older U.S. adults.

OBJECTIVES: To evaluate the association between serum 25‐hydroxyvitamin D (25(OH)D) levels and mortality in a representative U.S. sample of older adults.

The effect of intensive endurance exercise training on body fat distribution in young and older men

Little is known about the effects of exercise interventions on the distribution of central and/or intra-abdominal (IA) fat, and until now there were no studies in the elderly. Therefore, in this study we investigated the effects of an intensive 6-month endurance training program on overall body composition (hydrostatic weighing), fat distribution (body circumferences), and specific fat depots (computed tomography [CT]), in healthy young (n = 13; age, 28.2 +/- 2.4 years) and older (n = 15; age, 67.5 +/- 5.8 years) men. At baseline, overall body composition was similar in the two groups, except for a 9% smaller fat free mass in the older men (P less than .05). The thigh and arm circumferences were smaller (P = .001 and P less than .05, respectively), while the waist to hip ratio (WHR) was slightly greater in the older men (0.92 +/- 0.04 v 0.97 +/- 0.04, P less than .01). Compared with the relatively small baseline differences in body composition and circumferences, CT showed the older men to have a twofold greater IA fat depot (P less than .001), 48% less thigh subcutaneous (SC) fat (P less than .01), and 21% less thigh muscle mass (P less than .001). Following endurance (jog/bike) training, both the young (+18%, P less than .001) and the older men (+22%, P less than .001) significantly increased their maximal aerobic power (VO2max). This was associated with small but significant decrements in weight, percent body fat, and fat mass (all P less than .001) only in the older men.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of endurance exercise training on heart rate variability at rest in healthy young and older men

Heart rate variability (HRV) (SD of the RR interval), an index of parasympathetic tone, was measured at rest and during exercise in 13 healthy older men (age 60 to 82 years) and 11 healthy young men (age 24 to 32 years) before and after 6 months of aerobic exercise training. Before exercise training, the older subjects had a 47% lower HRV at rest compared with the young subjects (31 +/- 5 ms vs 58 +/- 4 ms, p = 0.0002). During peak exercise, the older subjects had less parasympathetic withdrawal than the young subjects (-45% vs -84%, p = 0.0001). Six months of intensive aerobic exercise training increased maximum oxygen consumption by 21% in the older group and 17% in the young group (analysis of variance: overall training effect, p = 0.0001; training effect in young vs old, p = NS). Training decreased the heart rate at rest in both the older (-9 beats/min) and the young groups (-5 beats/min, before vs after, p = 0.0001). Exercise training increased HRV at rest (p = 0.009) by 68% in the older subjects (31 +/- 5 ms to 52 +/- 8 ms) and by 17% in the young subjects (58 +/- 4 ms to 68 +/- 6 ms). Exercise training increases parasympathetic tone at rest in both the healthy older and young men, which may contribute to the reduction in mortality associated with regular exercise.

Endurance exercise training augments diastolic filling at rest and during exercise in healthy young and older men

BackgroundDiastolic filling at rest is altered markedly with advancing age. Whether exercise trainingcan improve diastolic filling at rest or during exercise in either healthy older or healthy young men has not been determined. The purpose of this study was to determine if 6 months of aerobic exercise training improves diastolic filling. Methods and ResultsRadionuclide diastolic filling parameters were measured at rest and during exercise in 14 older (age, 60 to 82 years) and 17 young (age, 24 to 32 years) rigorously screened healthy males before exercise training and in 13 older and 11 young men after 6 months of endurance exercise training. Diastolic filling rates were expressed in two ways, as absolute milliliters of blood (mL.s-1. m-2) and normalized to the end-diastolic volume. At baseline, the peak early filling rates were lower in the older group compared with the young group as expressed in absolute milliliters of blood (older, 85 7 mL. s-1. m-2; young, 173+ 10 mL. s-1 m2; P<.0001) and in end-diastolic volume per second (1.66+0.11 versus 2.55 ± 0.08, p<.0001), whereas the peak atrial filling rates were greater in absolute milliliters of blood (85 ± 5 versus 56 ± 7 mL. s-1. m-2, P=.003) and in end-diastolic volume per second (1.70 ± 0.12 versus 0.80+0.06, p<.0001). During exercise, at any given heart rate, the older group had a lower peak filling rate than the young group. Also, at peak exercise, the single peak filling rate was decreased in the older group in mL. S m-2 (384 ± 19 versus 565 ± 36 mL. s-1 m-2, P=.0002) and in end-diastolic volume per second (6.01 ± 0.25 versus 7.91+0.28 end-diastolic volume per second, p<.0001). Six months of intensive aerobic exercise training had similar effects in the old and young groups overall. Maximal oxygen consumption increased 19% (ANOVA training effect, p<.0001) and echocardiographic left ventricular mass increased 8% (ANOVA training effect, P=.002). Training increased the resting peak early filling rate in absolute milliliters of blood by +14% (ANOVA training effect, P=.02). During exercise, the peak eariy or single peak filling rate at any given heart rate was increased. At peak exercise, the single peak filling rate was increased by 14% in mL s-1. m-2 (ANOVA training effect, P=.0004). The only age-related differential effect of training was on the peak atrial filling rate in end-diastolic volume per second, which decreased by 27% in the older group but was unchanged in the young (+5%) (ANOVA young versus older, P=.001). The independent predictors of a greater maximal oxygen consumption by multivariate analysis were a higher peak exercise heart rate, a greater resting peak early filling rate, the exercise trained state, and a younger age. ConclusionHealthy older men have reduced early diastolic filling at rest and during exercise compared with young men. Endurance exercise training enhances early diastolic filling at rest and during exercise in both the old and the young. Training reduces the elevated resting atrial filling rate in the old, whereas the young were unchanged. The training-induced augmentation of early diastolic filling at rest and during exercise may be an important adaptation to allow an increase in stroke volume at rest and an increase in stroke volume, cardiac output, and maximal oxygen consumption during exercise.

Continuous-scale physical functional performance in healthy older adults: A validation study

OBJECTIVE The continuous-scale physical functional performance test (CS-PFP) is an original instrument designed to provide a comprehensive, in-depth measure of physical function that reflects abilities in several separate physical domains. It is based on a concept of physical function as the integration of physiological capacity, physical performance, and psychosocial factors. SETTING The test was administered under standard conditions in a hospital facility with a neighborhood setting. The CS-PFP consists of a battery of 15 everyday tasks, ranging from easy to demanding, that sample the physical domains of upper and lower body strength, upper body flexibility, balance and coordination, and endurance. Participants are told to work safely but at maximal effort, and physical functional performance was measured as weight, time, or distance. Scores were standardized and scaled 0 to 12. The test yields a total score and separate physical domain scores. DESIGN The CS-PFP was evaluated using 148 older adults-78 community dwellers, 31 long-term care facility residents living independently, and 39 residents with some dependence. MAIN OUTCOME MEASURES Maximal physical performance assessment included measures of maximal oxygen consumption (VO2max), isokinetic strength, range of motion, gait, and balance. Psychosocial factors were measured as self-defined health status using the Sickness Impact Profile (SIP), self-perceived function using the Health Survey (SF36), and Instrumental Activities of Daily Living (IADL). RESULTS IADL scores were not significantly different among the groups. Test-retest correlations ranged from .84 to .97 and inter-rater reliability from .92 to .99 for the CS-PFP total and 5 domains. Internal consistency was high (Cronbachs alpha, .74 to .97). Both total and individual domain CS-PFP scores were significantly different for the three groups of study participants, increasing with higher levels of independence, supporting construct validity. CS-PFP domain scores were significantly correlated with measures of maximal physical performance (VO2max, strength, etc) and with physical but not emotional aspects of self-perceived function. CONCLUSION The CS-PFP is a valid, reliable measure of physical function, applicable to a wide range of functional levels, and having minimal floor and ceiling effect. The total and physical domains may be used to evaluate, discriminate, and predict physical functional performance for both research and clinical purposes.

Differences in cardiovascular responses to isoproterenol in relation to age and exercise training in healthy men.

BackgroundCardiac aging is characterized by a reduced heart rate response to β-agonist stimulation with isoproterenol, but whether the ejection fraction and other cardiovascular responses are reduced in humans is largely unknown. In addition, whether reduced β-agonist responses can be improved with exercise training has not been determined in humans. Methods and ResulsCardiovascular responses to graded isoproterenol infusions (3.5, 7, 14, and 35 ng/kg/min for 14 minutes each) were assessed in 15 older (age, 60–82 years) and 17 young (age, 24–32 years) rigorously screened healthy men. Thirteen older and 11 young subjects completed 6 months of endurance training and were retested. At baseline, the older group had reduced responses to isoproterenol for heart rate (+65% older versus +92% young, p < 0.001), systolic blood pressure (+9% versus +24%, p < 0.001), diastolic blood pressure (−12% versus −24%, p < 0.05), ejection fraction (+12 versus +20 ejection fraction units, p < 0.001), and cardiac output (+70% versus +100%, p < 0.001). The mean plasma isoproterenol concentrations achieved during the infusions were marginally higher (p = 0.07) in the older group (128±58, 227±64, 354±114, and 700±125 pg/ml) than in the young (79±20, 178±49, 273±79, and 571±139 pg/ml). Intensive training increased maximal oxygen consumption by 21% in the older group (28.9±4.6 to 35.1±3.8 ml/kg/min, p < 0.001) and by 17% in the young (44.5±5.1 to 52.1±63 ml/kg/min, p < 0.001), but training did not augment any of the cardiovascular responses to isoproterenol in either group. The mean plasma isoproterenol concentrations at the four infusion doses were unchanged after training in both groups. ConclusionsWe conclude that there is an age-associated decline in heart rate, blood pressure, ejection fraction, and cardiac output responses to β-adrenergic stimulation with isoproterenol in healthy men. Altered β-adrenergic responses probably contribute to the reduced cardiac responses to maximal exercise that also occur with aging. Furthermore, intensive exercise training does not increase cardiac responses to β-adrenergic stimulation with isoproterenol in either young or older men. The reduced β-adrenergic response appears to be a primary age-associated change that is not caused by disease or inactivity.

Effect of a yearlong, moderate-intensity exercise intervention on the occurrence and severity of menopause symptoms in postmenopausal women

Objective:To evaluate the effect of moderate-intensity exercise on the occurrence and severity of menopause symptoms. Design:A yearlong, randomized, clinical trial, conducted in Seattle, WA, with 173 overweight, postmenopausal women not taking hormone therapy in the previous 6 months. The intervention was a moderate-intensity exercise intervention (n = 87) versus stretching control group (n = 86). Using logistic regression, odds ratios comparing exercise with controls were calculated at 3, 6, 9, and 12 months for menopause symptoms and their severity. Results:There was a significant increase in hot flash severity and decreased risk of memory problems in exercisers versus controls over 12 months, although the numbers affected were small. No other significant changes in symptoms were observed. Conclusions:Exercise does not seem to decrease the risk of having menopause symptoms in overweight, postmenopausal women not taking hormone therapy and may increase the severity of some symptoms in a small number of women.

Exercise for People in Early- or Mid-Stage Parkinson Disease: A 16-Month Randomized Controlled Trial

Background Exercise confers short-term benefits for individuals with Parkinson disease (PD). Objective The purpose of the study was to compare short- and long-term responses among 2 supervised exercise programs and a home-based control exercise program. Design The 16-month randomized controlled exercise intervention investigated 3 exercise approaches: flexibility/balance/function exercise (FBF), supervised aerobic exercise (AE), and home-based exercise (control). Setting This study was conducted in outpatient clinics. Patients The participants were 121 individuals with PD (Hoehn & Yahr stages 1–3). Interventions The FBF program (individualized spinal and extremity flexibility exercises followed by group balance/functional training) was supervised by a physical therapist. The AE program (using a treadmill, bike, or elliptical trainer) was supervised by an exercise trainer. Supervision was provided 3 days per week for 4 months, and then monthly (16 months total). The control group participants exercised at home using the National Parkinson Foundation Fitness Counts program, with 1 supervised, clinic-based group session per month. Measurements Outcomes, obtained by blinded assessors, were determined at 4, 10, and 16 months. The primary outcome measures were overall physical function (Continuous Scale—Physical Functional Performance [CS-PFP]), balance (Functional Reach Test [FRT]), and walking economy (oxygen uptake [mL/kg/min]). Secondary outcome measures were symptom severity (Unified Parkinsons Disease Rating Scale [UPDRS] activities of daily living [ADL] and motor subscales) and quality of life (39-item Parkinsons Disease Quality of Life Scale [PDQ-39]). Results Of the 121 participants, 86.8%, 82.6%, and 79.3% completed 4, 10, and 16 months, respectively, of the intervention. At 4 months, improvement in CS-PFP scores was greater in the FBF group than in the control group (mean difference=4.3, 95% confidence interval [CI]=1.2 to 7.3) and the AE group (mean difference=3.1, 95% CI=0.0 to 6.2). Balance was not different among groups at any time point. Walking economy improved in the AE group compared with the FBF group at 4 months (mean difference=−1.2, 95% CI=−1.9 to −0.5), 10 months (mean difference=−1.2, 95% CI=−1.9 to −0.5), and 16 months (mean difference=−1.7, 95% CI=−2.5 to −1.0). The only secondary outcome that showed significant differences was UPDRS ADL subscale scores: the FBF group performed better than the control group at 4 months (mean difference=−1.47, 95% CI=−2.79 to −0.15) and 16 months (mean difference=−1.95, 95% CI=−3.84 to −0.08). Limitations Absence of a non-exercise control group was a limitation of the study. Conclusions Findings demonstrated overall functional benefits at 4 months in the FBF group and improved walking economy (up to 16 months) in the AE group.

Epidemiology of weight loss in humans with special reference to wasting in the elderly

Unintentional weight loss in older adults is a problem that occurs frequently in clinical practice. Although slight declines in weight have been observed with aging alone, clinically important weight loss (decrements of 5% or more of usual body weight) is almost always the result of disease, disuse, and/or psychosocial factors. Adverse health outcomes associated with weight loss include decreased functional abilities and increased morbidity and mortality. Case series and prospective studies have helped to identify the most common causes of weight loss in older adults, and are reviewed herein. Knowledge of these frequent underlying etiologies can help guide an appropriate and cost-effective evaluation of patients presenting with weight loss. In many cases the causes are remediable and weight loss may slow or reverse with appropriate intervention. In some cases no clear etiology can be identified but the patient may still respond to nutritional support therapies that include hypercaloric feeding and appetite stimulants. Increasing caloric intake alone, however, is usually not sufficient to mitigate against losses in body mass (especially muscle mass) that are the result of chronic inflammatory or other severe disease states (cachexia). Potential strategies to help reduce losses in lean body mass and the functional decline that often accompanies weight loss include anabolic agents, exercise/physical activity, and cytokine inhibition. This article reviews the epidemiology of weight loss in older adults with special attention to the problem of cachexia. Diagnostic and treatment algorithms are provided to help guide clinical evaluation of, and therapeutic interventions for, older adults presenting with weight loss.