Sarcopenia Woo, Jean
Clinics in geriatric medicine,
08/2017, Letnik:
33, Številka:
3
Journal Article
Recenzirano
Sarcopenia refers to age-related muscle loss, defined using a combination of appendicular muscle mass, muscle strength, and physical performance measures. The pathogenesis depends on a balance ...between positive and negative regulators of muscle growth. Sarcopenia increases the risk for falls, fractures, dependency, use of hospital services, institutionalization, poor quality of life, and mortality. In clinical practice, brief screening tools, such as the 5-item SARC-F score, may be useful. Although pharmacologic treatments are actively being studied, the current mainstay consists of optimizing nutrition status, in particular protein and vitamin D status, and resistance exercises.
Purpose of Review
The relationship between successful aging, frailty, intrinsic capacity, and resilience is explored, in terms of underlying physiology, indicators, and utility.
Recent Findings
...Frailty may be regarded as the reverse of successful aging conceptually, but more appropriate for clinical management and health promotion programs. Intrinsic capacity may be used as indicator of healthy aging, and the concept of resilience more relevant in research efforts to understand the heterogeneous age-related changes. In prevention of geriatric syndromes and diseases, as well as in the formulation of health policies, the use of a negative undesirable state (such as frailty) may elicit more response than the alternative approach of maintaining intrinsic capacity. For example, smoking cessation strategies heavily use negative images, as opposed to “maintaining good lung function.” Similarly, in hospital management, frailty assessment has rapidly become incorporated into management in various specialties such as cardiology, renal medicine, and oncology, in addition to Geriatric Medicine and primary care.
Summary
Successful aging, frailty, resilience, and intrinsic capacity share many common features; the use of these terms represents different approaches towards describing age-related changes at all levels: from cellular, physiological systems, to whole persons and community.
Frailty is a complex age-related clinical condition characterised by a decline in physiological capacity across several organ systems, with a resultant increased susceptibility to stressors. Because ...of the heterogeneity of frailty in clinical presentation, it is important to have effective strategies for the delivery of care that range across the continuum of frailty severity. In clinical practice, we should do what works, starting with frailty screening, case identification, and management of frailty. This process is unarguably difficult given the absence of an adequate evidence base for individual and health-system interventions to manage frailty. We advocate change towards individually tailored interventions that preserve an individual's independence, physical function, and cognition. This change can be addressed by promoting the recognition of frailty, furthering advancements in evidence-based treatment options, and identifying cost-effective care delivery strategies.
Using data from the Hong Kong Mr and Ms Os study, we validated the SARC-F against 3 consensus definitions of sarcopenia from Europe, Asia, and an international group, and compared the ability of all ...4 measures to predict 4-year physical limitation, walking speed, and repeated chair stands.
Prospective cohort study.
Hong Kong community.
Four thousand men and women living in the community.
A questionnaire regarding ability to carry a heavy load, walking, rising from a chair, climbing stairs, and falls frequency was administered. These questions were used to calculate the SARC-F score. Measurements, including appendicular muscle mass, were taken using dual-energy X-ray, grip strength using a dynamometer, 6-m gait speed, and time taken for repeated chair stand. Classification using the SARC-F score was compared using consensus panel criteria from international, European, and Asian sarcopenia working groups. The performance of all 4 methods was compared by examining the predictive ability for 4-year outcomes using ROC curve.
The SARC-F has excellent specificity but poor sensitivity for sarcopenia classification; however, all 4 methods have comparable but modest predictive power for 4-year physical limitation.
The SARC-F may be considered a suitable tool for community screening for sarcopenia.
Objectives
To compare three simple bedside tools based on frailty phenotypes with a Frailty Index using the multiple deficit approach in the prediction of mortality and physical limitation after ...4 years.
Design
Cohort study.
Setting
Hong Kong, China.
Pariticipants
Four thousand men and women aged 65 and older living in the community who were ambulatory enough to attend the study center.
Methods
Interviewers obtained information regarding physical, psychological, and functional health; body mass index (BMI), grip strength, blood pressure, and ankle brachial index were determined. Three clinical frailty scales based on the Fried phenotype (Cardiovascular Health Study (CHS); Fatigue, Resistance, Ambulation, Illness, and Loss (FRAIL); and Hubbard) and a frailty index (FI) were constructed from these variables, and their ability to predict incident mortality and physical function limitations was compared using receiver operating characteristic (ROC) curves.
Results
All tools predicted adverse outcomes. More participants were categorized into frail and prefrail categories using the CHS than with the other two clinical scales. For all frailty measures, with increasing levels of frailty, the sensitivity fell and the specificity increased to greater than 90%; the area under the ROC curve values were approximately 0.6.
Conclusion
Simple frailty scores are comparable with a multidimensional deficit accumulation FI in predicting mortality and physical limitations. The newer FRAIL, proposed for use in a clinical setting, is comparable with other existing short screening tools, as well as tools based on the multiple‐deficits model used for research settings. Addition of a physical performance measure to screening tools may increase predictive accuracy.
We examined whether sarcopenia is predictive of incident fractures among older men, whether the inclusion of sarcopenia in models adds any incremental value to bone mineral density (BMD), and whether ...sarcopenia is associated with a higher risk of fractures in elderly with osteoporosis.
A cohort of 2000 community-dwelling men aged ≥65 years were examined for which detailed information regarding demographics, socioeconomic, medical history, clinical, and lifestyle factors were documented. Body composition and BMD were measured using dual energy X-ray absorptiometry. Sarcopenia was defined according to the Asian Working Group for Sarcopenia (AWGS) algorithm. Incident fractures were documented during the follow-up period from 2001 to 2013, and related to sarcopenia and its component measures using Cox proportional hazard regressions. The contribution of sarcopenia for predicting fracture risk was evaluated by receiver operating characteristic analysis, net reclassification improvement (NRI), and integrated discrimination improvement (IDI).
During an average of 11.3 years of follow-up, 226 (11.3%) men sustained at least 1 incident fracture, making the incidence of fractures 1200.6/100,000 person-years. After multivariate adjustments, sarcopenia was associated with increased fracture risk (hazard ratio HR, 1.87, 95% confidence interval CI, 1.26-2.79) independent of BMD and other clinical risk factors. The addition of sarcopenia did not significantly increase area under curve or IDI but significantly improved the predictive ability on fracture risk over BMD and other clinical risk factors by 5.12% (P < .05) using the NRI approach. In addition, the combination of osteoporosis and sarcopenia (sarco-osteoporosis) resulted in a significantly increased risk of fractures (HR, 3.49, 95% CI, 1.76-6.90) compared with those with normal BMD and without sarcopenia.
This study confirms that sarcopenia is a predictor of fracture risk in this elderly men cohort, establishes that sarcopenia provides incremental predictive value for fractures over the integration of BMD and other clinical risk factors, and suggests that the combination of osteoporosis and sarcopenia could identify a subgroup with a particularly high fracture risk.
To explore the feasibility of using the FRAIL scale in community screening of older Chinese people aged 65 years and older, followed by clinical validation by comprehensive geriatric assessment of ...those classified as pre-frail or frail.
Two-phase study: screening of people aged 65 years and older by trained volunteers, followed by comprehensive geriatric assessment by multidisciplinary staff for those classified as pre-frail or frail.
Elderly Centers in the New Territories East Region of Hong Kong SAR China.
A total of 816 members of elderly centers attending by themselves or accompanied by relatives.
For phase 1, questionnaire (including demographic, lifestyle, chronic diseases) and screening tools were administered by trained volunteers. These consist of the FRAIL scale, SARC-F to screen for sarcopenia, and mild cognitive impairment using the abbreviated screening for mild cognitive impairment (Abbreviated Memory Inventory for the Chinese). Blood pressure, body mass index, and grip strength were recorded. For phase 2, comprehensive geriatric assessment include questionnaires assessing lifestyle domain (physical activity, nutritional status using the Mini-Nutritional Assessment-Short Form), the physical domain (number of diseases and number of drugs, activities of daily living and instrumental activities of daily living disabilities, geriatric syndromes, self-rated health, sleep quality), cognitive and psychological domain (Mini-Mental State Examination, Geriatric Depression Scale), and social domain (income, housing, living satisfaction, family support).
The prevalence of pre-frailty and frailty were 52.4% and 12.5%, respectively. The prevalence for frailty increasing with age from 5.1% for those aged 65-69 years to 16.8% for those ≥75, being greater in women compared with men (13.9% vs 4.2%). Of those who were pre-frail or frail (n = 529), 42.5% had sarcopenia and 60.7% had mild cognitive impairment. Among those who were frail (n = 102), sarcopenia and mild cognitive impairment were also frequently present: 12.8% had sarcopenia, 14.7% had mild cognitive impairment, 63.7% had both sarcopenia and mild cognitive impairment, and only 8.8% had neither. In phase 2, participants who were classified as pre-frail or frail (n = 529) were invited for further interviews; 255 participants (48.2%) returned. Compared with the pre-frail group, those in the frail group were less physically active, had higher number of chronic diseases, were taking more medications (more were taking sleeping pills), reported more falls, rated their health as poor, had higher prevalence of depressive symptoms and mild cognitive impairment, had higher prevalence of sarcopenia, and a high number of activities of daily living and instrumental activities of daily living disabilities.
The FRAIL scale may be used as the first step in a step care approach to detecting frailty in the community, allowing targeted intervention to potentially retard decline and future disability.
Dietary pattern analysis has recently emerged as an alternative approach to investigate the association between diet and sarcopenia. This study examined the association of dietary patterns with ...sarcopenia in Chinese community-dwelling older people.
Chinese men and women aged 65 years or older participating in a cohort study examining the risk factors for osteoporosis completed a validated food frequency questionnaire at baseline between 2001 and 2003. Adherence to a priori dietary patterns, namely the Diet Quality Index-International (DQI-I) and the Mediterranean Diet Score (MDS) was assessed. Factor analysis identified 3 a posterior dietary patterns: "vegetables-fruits," "snacks-drinks-milk products," and "meat-fish." Sarcopenia was defined using the Asian Working Group for Sarcopenia algorithm. Multiple logistic regression was used for cross-sectional analysis (n = 3957) to assess the associations between dietary patterns and prevalent sarcopenia, and for longitudinal analysis (n = 2948) on their associations with 4-year incident sarcopenia with adjustment for sociodemographic and lifestyle factors.
There were 290 (7.3%) (185 men, 105 women) sarcopenic cases at baseline and 264 (9.0%) (160 men, 104 women) incident sarcopenic cases at the 4-year follow-up. At baseline, men in the highest quartile of DQI-I had reduced odds of sarcopenia (Adjusted OR 0.50, 95% CI 0.31-0.81, Ptrend = .004) compared with men in the lowest quartile. Men in the highest quartile of "vegetables-fruits" pattern score (Adjusted OR 0.60, 95% CI 0.36-0.99, Ptrend = .034) showed lower likelihood of sarcopenia compared with men in the lowest quartile. Higher quartile of "snacks-drinks-milk products" pattern score was associated with lower odds of sarcopenia in men (Adjusted OR 0.41, 95% CI 0.24-0.70, Ptrend < .001). There was no association between dietary patterns and prevalent sarcopenia in women. None of the dietary patterns was associated with incident sarcopenia at 4-year in both sexes.
Higher DQI-I, higher "vegetables-fruits" dietary pattern score, and higher "snacks-drinks-milk products" dietary pattern score were associated with lower odds of prevalent sarcopenia in Chinese older men.
Frailty may be used as a public health indicator of aging well for projection of health and social care resource allocation. Frailty assessments have been adopted by various medical as well as ...surgical specialties as part of prognosis in influencing choice of therapy, although the assessment tools are even more heterogeneous than those in the gerontological fields. Recently, the World Health Organization called for a life course approach to healthy aging, placing the emphasis on function, expressed as intrinsic capacity, which would address concerns with the negative image of frailty and with the overemphasis on deficits. The impact of social and physical environments is taken into account in the concept of resilience. These are all related concepts that differ in the setting in which they are used. Frailty may be more useful in clinical management in hospitals and residential care homes, as well as in community models of care. Intrinsic capacity could be used for development of health‐promotion policies and service models across the life course; mainly primary care with low resource needs, using a step‐care approach. Resilience could be considered an overarching holistic concept covering physical, psychological, and environmental domains, which is still in the research arena.
To develop Clinical Practice Guidelines for the screening, assessment and management of the geriatric condition of frailty.
An adapted Grading of Recommendations, Assessment, Development, and ...Evaluation approach was used to develop the guidelines. This process involved detailed evaluation of the current scientific evidence paired with expert panel interpretation. Three categories of Clinical Practice Guidelines recommendations were developed: strong, conditional, and no recommendation.
Strong recommendations were (1) use a validated measurement tool to identify frailty; (2) prescribe physical activity with a resistance training component; and (3) address polypharmacy by reducing or deprescribing any inappropriate/superfluous medications. Conditional recommendations were (1) screen for, and address modifiable causes of fatigue; (2) for persons exhibiting unintentional weight loss, screen for reversible causes and consider food fortification and protein/caloric supplementation; and (3) prescribe vitamin D for individuals deficient in vitamin D. No recommendation was given regarding the provision of a patient support and education plan.
The recommendations provided herein are intended for use by healthcare providers in their management of older adults with frailty in the Asia Pacific region. It is proposed that regional guideline support committees be formed to help provide regular updates to these evidence-based guidelines.
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