Context Type 2 diabetes is associated with higher bone density (BMD) and, paradoxically, with increased fracture risk. It is not known if low BMD, central to fracture prediction in older adults, identifies fracture risk in diabetic patients. Objective Determine if femoral neck (FN) BMD T-score and FRAX score are associated with fracture in older diabetic adults. Design Three observational studies: Study of Osteoporotic Fractures, Osteoporotic Fractures in Men, and Health, Aging and Body Composition study. Setting Older community-dwelling adults in U.S. Participants 9,449 women; 7,436 men. Main outcome measure(s) Self-reported incident fractures, verified by radiology reports. Results Of 770 diabetic women, 84 experienced a hip and 262 a non-spine fracture during mean (SD) follow-up of 12.6 (5.3) years. Of 1,199 diabetic men, 32 experienced a hip and 133 a non-spine fracture during mean follow-up of 7.9 (2.5) years. Age-adjusted hazard ratios (HR) for one unit decrease in FN BMD T-score in diabetic women were 1.88 (95% confidence interval [CI], 1.43–2.48) for hip and 1.52 (95% CI, 1.31–1.75) for non-spine fracture. HRs in diabetic men were 5.71 (95% CI, 3.42–9.53) for hip and 2.17 (95% CI, 1.75–2.69) for non-spine fracture. FRAX score was also associated with fracture risk in diabetic participants. However, for a given T-score and age or FRAX score, diabetic participants had a higher fracture risk than those without diabetes. For a similar hip fracture risk, diabetic participants had a higher T-score than non-diabetic participants. The difference in T-score was 0.59 (95% CI, 0.31–0.87) for women and 0.38 (95% CI, 0.09–0.66) for men. Conclusions Among older adults with type 2 diabetes, FN BMD T-score and FRAX score were associated with hip and non-spine fracture risk. However, in these patients, compared with participants without diabetes, fracture risk was higher for a given T-score and age or a given FRAX score.

The OEP may reduce falls by improving cognitive performance.

Nutritional support and intervention is an integral component of head and neck cancer management. Patients can be malnourished at presentation, and the majority of patients undergoing treatment for head and neck cancer will need nutritional support. This paper summarises aspects of nutritional considerations for this patient group and provides recommendations for the practising clinician.Recommendations• A specialist dietitian should be part of the multidisciplinary team for treating head and neck cancer patients throughout the continuum of care as frequent dietetic contact has been shown to have enhanced outcomes. (R)• Patients with head and neck cancer should be nutritionally screened using a validated screening tool at diagnosis and then repeated at intervals through each stage of treatment. (R)• Patients at high risk should be referred to the dietitian for early intervention. (R)• Offer treatment for malnutrition and appropriate nutrition support without delay given the adverse impact on clinical, patient reported and financial outcomes. (R)• Use a validated nutrition assessment tool (e.g. scored Patient Generated–Subjective Global Assessment or Subjective Global Assessment) to assess nutritional status. (R)• Offer pre-treatment assessment prior to any treatment as intervention aims to improve, maintain or reduce decline in nutritional status of head and neck cancer patients who have malnutrition or are at risk of malnutrition. (G)• Patients identified as well-nourished at baseline but whose treatment may impact on their future nutritional status should receive dietetic assessment and intervention at any stage of the pathway. (G)• Aim for energy intakes of at least 30 kcal/kg/day. As energy requirements may be elevated post-operatively, monitor weight and adjust intake as required. (R)• Aim for energy and protein intakes of at least 30 kcal/kg/day and 1.2 g protein/kg/day in patients receiving radiotherapy or chemoradiotherapy. Patients should have their weight and nutritional intake monitored regularly to determine whether their energy requirements are being met. (R)• Perform nutritional assessment of cancer patients frequently. (G)• Initiate nutritional intervention early when deficits are detected. (G)• Integrate measures to modulate cancer cachexia changes into the nutritional management. (G)• Start nutritional therapy if undernutrition already exists or if it is anticipated that the patient will be unable to eat for more than 7 days. Enteral nutrition should also be started if an inadequate food intake (60 per cent of estimated energy expenditure) is anticipated for more than 10 days. (R)• Use standard polymeric feed. (G)• Consider gastrostomy insertion if long-term tube feeding is necessary (greater than four weeks). (R)• Monitor nutritional parameters regularly throughout the patient's cancer journey. (G)• Pre-operative:○ Patients with severe nutritional risk should receive nutrition support for 10–14 days prior to major surgery even if surgery has to be delayed. (R)○ Consider carbohydrate loading in p...

Dialysis patients are increasingly older and more disabled. In community-dwelling seniors without kidney disease, falls commonly predict hospitalization, the onset of frailty, and the need for institutional care. Effective fall prevention strategies are available. On the basis of retrospective data, it was hypothesized that the fall rates of older (>65 yr) chronic outpatient hemodialysis (HD) patients would be higher than published rates for community-dwelling seniors (0.6 to 0.8 falls/patientyear). It also was hypothesized that risk factors for falls in dialysis outpatients would include polypharmacy, dialysis-related hypotension, cognitive impairment, and decreased functional status. Using a prospective cohort study design, HD patients who were >65 yr of age at a large academic dialysis unit were recruited. All study participants underwent baseline screening for fall risk factors. Patients were followed prospectively for a minimum of 1 yr. Falls were identified through biweekly patient interviews in the HD unit. A total of 162 patients (mean age 74.7 yr) were recruited; 57% were male. A total of 305 falls occurred in 76 (47%) patients over 190.5 person-years of follow-up (fall-incidence 1.60 falls/person-year). Injuries occurred in 19% of falls; 41 patients had multiple falls. Associated risk factors included age, comorbidity, mean predialysis systolic BP, and a history of falls. In the HD population, the fall risk is higher than in the general community, and fall-related morbidity is high. Better identification of HD patients who are at risk for falls and targeted fall intervention strategies are required.

In recent years, there has been a strong interest in physical activity as a primary behavioural prevention strategy against cognitive decline. A number of large prospective cohort studies have highlighted the protective role of regular physical activity in lowering the risk of cognitive impairment and dementia. The majority of prospective intervention studies of exercise and cognition to date have focused on aerobic-based exercise training. These studies highlight that aerobic-based exercise training enhances both brain structure and function. However, it has been suggested that other types of exercise training, such as resistance training, may also benefit cognition. The purpose of this brief review is to examine the evidence regarding resistance training and cognitive benefits. Three recent randomized exercise trials involving resistance training among seniors provide evidence that resistance training may have cognitive benefits. Resistance training may prevent cognitive decline among seniors via mechanisms involving IGF-1 and homocysteine. A side benefit of resistance training, albeit a very important one, is its established role in reducing morbidity among seniors. Resistance training specifically moderates the development of sarcopenia. The multifactorial deleterious sequelae of sarcopenia include increased falls and fracture risk as well as physical disability. Thus, clinicians should consider encouraging their clients to undertake both aerobic-based exercise training and resistance training not only for 'physical health' but also because of the almost certain benefits for 'brain health'.

We conclude that this group of community-dwelling fallers, who presented for ED care with a clinical profile suggesting a high risk of further falls and fracture, did not receive Guideline care and worsened in their fall risk profile by 29.5%. This gap in care, at least in one centre, suggests further investigation into alternative approaches to delivering Guideline standard health service.

The U.S. Preventive Services Task Force (USPSTF) recommends osteoporosis screening for women younger than 65 years whose 10-year predicted risk of major osteoporotic fracture is ≥ 9.3%. For identifying screening candidates among women aged 50-64 years, it is uncertain how the USPSTF strategy compares with the Osteoporosis Self-Assessment Tool (OST) and the Simple Calculated Osteoporosis Risk Estimate (SCORE). We examined data (1994-2012) from 5165 Women's Health Initiative participants aged 50-64. For the USPSTF (FRAX major fracture risk ≥ 9.3% calculated without BMD), OST (score <2), and SCORE (score >7) strategies, we assessed sensitivity, specificity, and area under the receiver operating characteristic curve (AUC) to discriminate between those with and without femoral neck (FN) T-score ≤ −2.5. Sensitivity, specificity, and AUC for identifying FN T-score ≤ −2.5 were 34.1%, 85.8%, and 0.60 for USPSTF (FRAX), 74.0%, 70.8%, and 0.72 for SCORE, and 79.8%, 66.3%, and 0.73 for OST. The USPSTF strategy identified about 1/3rd of women aged 50-64 with FN T-scores ≤ −2.5. Among women aged 50-64 years, the USPSTF strategy was modestly better than chance alone and inferior to conventional SCORE and OST strategies in discriminating between women with and without FN T-score ≤ −2.5.

SummaryMany falls occur among older adults with no traditional risk factors. We examined potential independent effects of lifestyle on fall risk. Not smoking and going outdoors frequently or infrequently were independently associated with more falls, indicating lifestyle-related behavioral and environmental risk factors are important causes of falls in older women.IntroductionPhysical and lifestyle risk factors for falls and population attributable risks (PAR) were examined.MethodsWe conducted a 4-year prospective study of 8,378 community-dwelling women (mean age = 71 years, SD = 3) enrolled in the Study of Osteoporotic Fractures. Data on number of falls were self-reported every 4 months. Fall rates were calculated (# falls/woman-years). Poisson regression was used to estimate relative risks (RR).ResultsPhysical risk factors (p ≤ 0.05 for all) included tall height (RR = 0.89 per 5 in.), dizziness (RR = 1.16), fear of falling (RR = 1.20), self-reported health decline (RR = 1.19), difficulty with Instrumental Activities of Daily Living (IADLs) (RR = 1.12, per item), fast usual-paced walking speed (RR = 1.18, per 2 SD), and use of antidepressants (RR = 1.20), benzodiazepines (RR = 1.11), or anticonvulsants (RR = 1.62). Protective physical factors (p ≤ 0.05 for all) included good visual acuity (RR = 0.87, per 2 SD) and good balance (RR = 0.85 vs. poor). Lifestyle predicted fewer falls including current smoking (RR = 0.76), going outdoors at least twice weekly but not more than once a day (RR = 0.89 and vs. twice daily). High physical activity was associated with more falls but only among IADL impaired women. Five potentially modifiable physical risk factors had PAR ≥ 5%.ConclusionsFall interventions addressing modifiable physical risk factors with PAR ≥ 5% while considering environmental/behavioral risk factors are indicated.