2020 ACP Guideline: testosterone supplementation for age-related hypogonadism

American College of Physician committee systematically reviewed 38 randomized controlled clinical trials involving testosterone supplementation in patients with age-related hypogonadism. Subjects’ mean age was 66 years, with average baseline total testosterone measures ≤300 ng/dL. Authors reached consensus on the following soft recommendations:

Physicians should be open to initiating testosterone therapy in adults with age-related hypogonadism only from the sexual dysfunction perspective. The decision to treat should be reached after a complete patient-physician discussion that includes pharmacological options, benefits, safety, and cost.

ACP recommends the intramuscular route of testosterone administration due to its low cost and similar efficacy and safety to other modes of therapy. They do not advise starting testosterone supplementation for other symptoms – apart from sexual dysfunction – such as reduced physical capacity, cognition, stamina, and vitality.

GT

Bisphosphonate infusion for osteopenia

A group of 2,000 women with osteopenia receiving either zoledronate infusion or placebo were followed for 6 years. Zoledronate 5 mg or placebo was provided every 1.5 years. At the end of the study, the intravenous bisphosphonate reduced vertebral and nonvertebral fractions significantly by about 55% and 35% respectively.

Findings are of major significance as bisphosphonates in general and zoledronate specifically have been approved only for osteoporosis and not osteopenia. Would this expand indications for zoledronate? Should patients with osteopenia be treated?

GT

Systolic Blood Pressure and Dementia Risk

About 9,000 adults were randomized to receive tight or less-tight systolic blood pressure control. They were followed for about 5 years for cognition and dementia outcomes.

Although the primary outcome was almost significant, the secondary outcomes were truly significant for improvement of mild cognitive impairment or probable dementia with intensive systolic blood pressure <120 mmHg over those who achieved sBP <140 mmHg.

While further trials are needed to clarify the above findings, there appears to be no harm of lowering the sBP down to <120 mmHg in this study.

GT

Subclinical hypothyroidism in the elderly

Personalized therapy is crucial in good clinical practice, and in the management of older patients with subclinical hypothyroidism, multiple factors must be considered, including age-dependent TSH cutoffs, thyroid autoimmunity, the burden of comorbidities, and the possible presence of frailty. 

Levothyroxine is the drug of choice for the treatment of hypothyroid older people, but the risk of overtreatment, potential adverse drug reactions, and patient compliance should always be considered and thyroid status periodically reassessed.

JES

Atrial fibrillation in aging adults

This is an important study evaluating the associative factors and natural history of atrial fibrillation. Until age 90, men are at higher risk of developing A.Fib compared to women. Tall women, and overweight and dyslipidemic men are more likely to experience it than their counterparts. Lifetime risk for Atrial fibrillation high, more than 30%. It increases the mortality rate by 3.5 fold in both genders. Subjects were followed for about 13 years.

GT

Elderly should consume more protein

The Recommended Daily Allowance (RDA) for protein intake in the adult population is widely promoted as 0.8 grams/kg/day. Aging may increase protein requirements, particularly to maintain muscle mass. 

Authors investigated whether controlled protein consumption at the current RDA or twice the RDA (2 x RDA) affects skeletal muscle mass and physical function in elderly men. 

Study found that consumption of a diet providing 2 x RDA for protein compared with the current guidelines was found to have beneficial effects on lean body mass and leg power in elderly men.

AJCN

Protein intake in aging adults

The anorexia of aging, which affects 20% of older adults, has been well documented within the current body of evidence as a primary cause of reduced daily intake in this population. This condition is characterized by reductions in appetite in combination with early satiation and sustained increases in satiety.

Circulating concentrations of the hunger-stimulating hormone ghrelin are lower, whereas the satiety hormones cholecystokinin, peptide YY, and GLP-1 are elevated in older adults compared with their younger counterparts. Gastric emptying also tends to be slower in older adults than in younger adults, which leads to early satiation. These responses occur concomitantly with an increase in perceived fullness and decreased hunger, desire to eat, and prospective food consumption.

Am J Clin Nutr

Insulin Resistance and Memory

Higher fasting insulin levels and increased insulin resistance predict future memory decline as measured by verbal fluency. About 4,000 individuals, average age 50, were followed for 11 years. These findings imply the need of addressing insulin resistance early rather then later, when prediabetes or diabetes emerge.

GT

Exercise effect in older sedentary adults

Combined aerobic and resistance activity increased physical performance more than aerobic or resistance training alone. A group of 160 sedentary individuals with average age 70 and BMI 35 were followed and evaluated at 6 months.

Results could be confounded by the fact that participants in the combined training group spent overall more time exercising than those who utilized only aerobic or resistance activities.

GT