Open Label Study for the Use of Transcranial Ultrasound for Treatment of Age-Related Frailty

Study Overview
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Brief Summary
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The purpose of this Phase I open label study is to evaluate longer term tolerability and potential effectiveness of transcranial ultrasound in people with age-related frailty.

Detailed Description
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This study is designed to evaluate the safety and efficacy of focused ultrasound in patients with age-related frailty characterized by reduced physical and immunological functioning. The safety of this protocol will be closely monitored and data will be used to determine whether any significant safety issues exist when using focused ultrasound. Adverse events will be noted whenever they occur but will be recorded at the time of the procedure and throughout routine follow-ups, which will persist weekly throughout the duration of the active study protocol. Patients deemed potentially appropriate candidates for focused ultrasound therapy will be treated with 8 sessions of transcranial ultrasound, each of which consists of 10 to 30 minutes of active administration. Clinical and safety outcome measures will be obtained throughout and after completion of the study protocol.

Official Title
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Open Label Study for the Use of Transcranial Ultrasound for Treatment of Age-Related Frailty

Conditions
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Frailty, Aging

Intervention / Treatment
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* Device: Focused Ultrasound


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Age eligibility requirements fall in a range from 60 to 95 years of age Clinical appraisal by physician indicating signs of frailty (apart from a co-occuring condition), scoring 3<x<7 as denoted by the CSHA Clinical Frailty Scale (Rockwood, Song, MacKnight, et al, 2005; Golpanian, DiFede, Pujol, et al., 2016) MRI of the brain including volume measurement of the hypothalamus Exclusion Criteria: Subjects unable to give informed consent Subjects who would not be able to lay down without excessive movement in a calm environment sufficiently long enough to be able to achieve sleep Pregnancy, women who may become pregnant or are breastfeeding Advanced terminal illness Subjects with scalp rash or open wounds on the scalp (for example from treatment of squamous cell cancer)

Ages Eligible for Study
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Minimum Age: 45 Years
Maximum Age: 95 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Intervention Model: Single Group Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Experimental<br>Participants will undergo ten to thirty minutes of transcranial ultrasound treatment. The sanitation device will be aimed at the hypothalamus. Targeting will include reference to scalp fiducials based on the obtained MRI; confirmation of target accuracy will either be obtained by Doppler waveform confirmation or optical tracking technology which co-registers patient neuroimaging with real space. | Device: Focused Ultrasound<br>* The DWL Doppler ultrasound device enables visual and auditory waveform confirmation of the middle cerebral artery, and optical tracking technology (e.g., AntNeuro Visor2™ system) may be used in tandem with the Brainsonix ultrasound device to track a patient's brain in virtual space as well as their physical location, thereby ensuring accurate placement.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Clinical Frailty Scale (CFS) | The CFS is a 9-point scoring guide for physicians to use upon clinical appraisal of frailty-related symptoms. The lowest rating is 1 (Very Fit) and the highest rating is 9 (Terminally Ill). The range of acceptable ratings for screened participants is from 3 (Managing Well) to 7 (Severely Frail). | Baseline | 
| Clinical Frailty Scale (CFS) | The CFS is a 9-point scoring guide for physicians to use upon clinical appraisal of frailty-related symptoms. The lowest rating is 1 (Very Fit) and the highest rating is 9 (Terminally Ill). The range of acceptable ratings for screened participants is from 3 (Managing Well) to 7 (Severely Frail). Scoring on the CFS will be noted as significant for those who improve by at least one level. | Final Evaluation (8 weeks from baseline) | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Short Physical Performance Battery (SPPB) | The SPPB is a series of tests used to evaluate lower extremity function and mobility in older people. The test consists of three major components, each of which are scored independently: 3 static balance tests, gait speed, and five timed sit-to-stand tests. Points are assigned based on performance, with a maximum possible score of 12 points. Higher scores are indicative of better functioning. A score of 0 on any item indicates lack of ability or functioning. The minimum clinically important difference for the total SPPB score is 1 point. | Baseline | 
| Short Physical Performance Battery (SPPB) | The SPPB is a series of tests used to evaluate lower extremity function and mobility in older people. The test consists of three major components, each of which are scored independently: 3 static balance tests, gait speed, and five timed sit-to-stand tests. Points are assigned based on performance, with a maximum possible score of 12 points. Higher scores are indicative of better functioning. A score of 0 on any item indicates lack of ability or functioning. The minimum clinically important difference for the total SPPB score is 1 point. | Final Evaluation (8 weeks from baseline) | 
| Multidimensional Fatigue Inventory (MFI) | The MFI is a 20-item scale designed to evaluate five dimensions of fatigue: general fatigue, physical fatigue, reduced motivation, reduced activity, and mental fatigue. Respondents use a scale ranging from 1 to 7 to indicate how aptly certain statements regarding fatigue represent their experiences. Several positively phrased items are reverse- scored. Higher total scores correspond with more acute levels of fatigue. Responses for the Multidimensional Fatigue Inventory will be defined as clinically significant when there is a 2-point difference. | Baseline | 
| Multidimensional Fatigue Inventory (MFI) | The MFI is a 20-item scale designed to evaluate five dimensions of fatigue: general fatigue, physical fatigue, reduced motivation, reduced activity, and mental fatigue. Respondents use a scale ranging from 1 to 7 to indicate how aptly certain statements regarding fatigue represent their experiences. Several positively phrased items are reverse- scored. Higher total scores correspond with more acute levels of fatigue. Responses for the Multidimensional Fatigue Inventory will be defined as clinically significant when there is a 2-point difference. | Final Evaluation (8 weeks from baseline) | 
| Montreal Cognitive Assessment (MoCA) | The MoCA evaluates frontal-executive functions (e.g., verbal abstraction and mental calculation), language (e.g., confrontation naming, phonemic fluency), orientation (e.g., person, place, date, day of the week, and time), visuospatial construction (e.g., simple figure copy), divided visual attention, and immediate and delayed memory of unstructured information. MoCA scores range from 0-30 possible points; 26 or greater is considered to reflect normal cognitive status. | Baseline | 
| Montreal Cognitive Assessment (MoCA) | The MoCA evaluates frontal-executive functions (e.g., verbal abstraction and mental calculation), language (e.g., confrontation naming, phonemic fluency), orientation (e.g., person, place, date, day of the week, and time), visuospatial construction (e.g., simple figure copy), divided visual attention, and immediate and delayed memory of unstructured information. MoCA scores range from 0-30 possible points; 26 or greater is considered to reflect normal cognitive status. | Final Evaluation (8 weeks from baseline) | 
| Beck Depression Inventory (BDI-II) | The BDI-II is a 21-question multiple-choice self-report inventory. Each question involves four possible responses, ranging in intensity from 0 (this item does not apply) to 3 (this item applies severely). The test is scored as the sum of all of the response values; this number is used to determine the severity of depressive symptoms. A score of 0 to 3 is possible for each question with a maximum total score of 63 points. The standard cutoff scores are as follows: 0-13 total points = minimal depression; 14-19 total points = mild depression; 20-28 total points = moderate depression; and 29-63 total points = severe depression. A reduction in the total score by at least 30% is considered to be clinically significant. | Baseline | 
| Beck Depression Inventory (BDI-II) | The BDI-II is a 21-question multiple-choice self-report inventory. Each question involves four possible responses, ranging in intensity from 0 (this item does not apply) to 3 (this item applies severely). The test is scored as the sum of all of the response values; this number is used to determine the severity of depressive symptoms. A score of 0 to 3 is possible for each question with a maximum total score of 63 points. The standard cutoff scores are as follows: 0-13 total points = minimal depression; 14-19 total points = mild depression; 20-28 total points = moderate depression; and 29-63 total points = severe depression. A reduction in the total score by at least 30% is considered to be clinically significant. | Final Evaluation (8 weeks from baseline) | 
| Beck Anxiety Inventory (BAI) | The BAI is a 21-question multiple-choice self-report inventory that is used for measuring the severity of anxiety symptoms. Each of the 21 items asks whether the patient has experienced various anxiety symptoms in the last two weeks, and if so, how severely. Each question/answer is scored on a scale value of 0 (not at all) to 3 (severely). Higher total scores indicate more severe anxiety symptoms. The maximum total score possible is 63 points. The standard cutoff scores are: 0-7 = minimal anxiety; 8-15 = mild anxiety; 16-25 = moderate anxiety; 26-63 = severe anxiety. A reduction in score by at least 30% is considered clinically meaningful. | Baseline | 
| Beck Anxiety Inventory (BAI) | The BAI is a 21-question multiple-choice self-report inventory that is used for measuring the severity of anxiety symptoms. Each of the 21 items asks whether the patient has experienced various anxiety symptoms in the last two weeks, and if so, how severely. Each question/answer is scored on a scale value of 0 (not at all) to 3 (severely). Higher total scores indicate more severe anxiety symptoms. The maximum total score possible is 63 points. The standard cutoff scores are: 0-7 = minimal anxiety; 8-15 = mild anxiety; 16-25 = moderate anxiety; 26-63 = severe anxiety. A reduction in score by at least 30% is considered clinically meaningful. | Final Evaluation (8 weeks from baseline) | 
| Community Healthy Activities Model Program for Seniors (CHAMPS) | This self-report questionnaire assesses weekly frequency and duration of a variety of lifestyle physical activities that are meaningful and appropriate for older adults. It includes activities of various intensities (from light to vigorous) such as walking, running, hiking, swimming, bicycling, dancing, tennis, aerobics, yoga/tai chi, gardening, and housework. Intensity is reflected in the item stem (e.g., light and heavy gardening are separate items). The questionnaire is self-administered, although it can be interviewer administered. It is formatted to accommodate increasing visual problems with age by using a large font, adequate space on the page, and high contrast. A total caloric expenditure is calculated based on reported participant activity. Responses for the CHAMPS questionnaire will be defined as clinically significant when there is a 8 kcal/kg/week difference. | Baseline | 
| Community Healthy Activities Model Program for Seniors (CHAMPS) | This self-report questionnaire assesses weekly frequency and duration of a variety of lifestyle physical activities that are meaningful and appropriate for older adults. It includes activities of various intensities (from light to vigorous) such as walking, running, hiking, swimming, bicycling, dancing, tennis, aerobics, yoga/tai chi, gardening, and housework. Intensity is reflected in the item stem (e.g., light and heavy gardening are separate items). The questionnaire is self-administered, although it can be interviewer administered. It is formatted to accommodate increasing visual problems with age by using a large font, adequate space on the page, and high contrast. A total caloric expenditure is calculated based on reported participant activity. Responses for the CHAMPS questionnaire will be defined as clinically significant when there is a 8 kcal/kg/week difference. | Final Evaluation (8 weeks from baseline) | 
| Grip Strength (Dynamometer Performance) | Participants will be asked to demonstrate grip strength in standard fashion for clinical evaluation. Using the JAMAR Technologies Hydraulic Hand Dynamometer, participants will squeeze the instrument with their dominant hand and generate a reading of grip strength in the output reading (units = kg). The MCID of the grip strength test is a change of at least 5.0 kg. | Baseline | 
| Grip Strength (Dynamometer Performance) | Participants will be asked to demonstrate grip strength in standard fashion for clinical evaluation. Using the JAMAR Technologies Hydraulic Hand Dynamometer, participants will squeeze the instrument with their dominant hand and generate a reading of grip strength in the output reading (units = kg). The MCID of the grip strength test is a change of at least 5.0 kg. | Final Evaluation (8 weeks from baseline) | 
| Global Rating of Change (GRC) | The GRC consists of a single likert-scale ranging from -5 (very much worse) to 0 (neutral/no change) to 5 (very much better). The GRC is obtained in an interview format to assess a patient's perceived change in status following a treatment. A score that is at least 2 or greater is considered to indicate clinically significant change. | Final Evaluation (8 weeks from baseline) |